Job Application | Community Health Centers of Southeastern Iowa

Name*

Email*

Phone*

What is the best time to reach you?*

Please enter a time to the nearest half hour.

Address*

Address

Street Address

Street 2 (Apartment, P.O. Box, etc)

City

State/Province

Zip/Postal

Please enter a street address where you can be reached.

Date of application:*

Position applying for:*

Salary/Hourly wage desired:*

Date available for employment:*

Type of Employment Desired:*

Regular Full-Time

Regular Part-Time

Temporary

Referral Source:

Referral Employee

Employment History

Please include complete and current information for each employer that you provide below.

Last (or current Employer):*

Date Employed From:*

Date Employed To:*

Employer Address:*

Employer phone number:*

Starting Salary & Final Salary:*

Position Title*

Immediate Supervisor/Title*

Supervisor's E-mail*

May We Contact?*

Yes

No

Reason for Leaving*

Describe Duties:*

Next most recent Employer:

Date Employed From:

Date Employed To:

Employer Address:

Employer Phone Number:

Starting Salary & Final Salary:

Position Title:

Immediate Supervisor/Title:

Supervisor's E-mail

Reason for Leaving:

Describe Duties:

Next most recent Employer:

Date Employed From:

Date Employed To:

Employer Address:

Employer Phone Number:

Starting Salary & Final Salary:

Position Title:

Immediate Supervisor/Title:

Supervisor's E-mail

Reason for Leaving:

Describe Duties:

Comments: (list special comments, including explanations for any "gaps" in your employment history):

Educational Background

What was your highest degree earned in school?*

Graduated High School

Graduated College

GED

High School Name

High School Address

City/State/Zip

High School Phone Number

Last Name While Attending/Upon Graduation

Years Attended High School

Month/Year Earned Degree/Diploma

High School Equivalency

High school Equivalency Diploma (HSED) Program College/Program Name (Where prepped and/or tested)

High School Equivalency Address

City/State/Zip

Phone Number

Last Name While Attending/Upon Graduation

High School Equivalency Years Attended

High School Equivalency Month/Year Earned

College/University Name

College Address

City/State/Zip

College Phone Number

College Years Attended

Month/Year Earned Degree/Diploma

College/University Name

College Address

City/State/Zip

College Phone Number

College Years Attended

Month/Year Earned Degree/Diploma

Professional Certifications and Licensures:

Licensure or Certification:

License Number:

Issue Date:

Expiration Date:

Licensure or Certification:

License Number:

Issue Date:

Expiration Date:

Licensure or Certification:

License Number:

Issue Date:

Expiration Date:

Licensure or Certification:

License Number:

Issue Date:

Expiration Date:

Special Skills and Qualifications

Please summarize any special skills and qualifications acquired from employment, education, or other experiences which may qualify you to work for CHC/SEIA. For clerical applicants please indicate typing speed, data entry capabilities, knowledge of computer programs, etc

Clubs and Associations

Include professional, trade, business or civic activities and offices held. You may exclude any memberships which would reveal gender, race, religion, national origin, age ancestry, disability or other protected status)

Foreign Language and/or Sign Language

Indicate any foreign languages and/or sign language, which might enable you to communicate with our non-English speaking or hearing impaired patients

For Clerical Applicants:

Please indicate typing speed, data entry capabilities, computer software programs and platforms with which you are proficient:

Typing Speed:

Date Entry:

Software program and platforms:

Additional Information:

Work overtime?*

Yes

No

CHC/SIEA reserves the right to assign hours to employees as necessary for the operation of the clinic.

Work some evenings?*

Yes

No

Work some weekends (Sat)?*

Yes

No

Travel if position requires?*

Yes

No

Have reliable transportation?*

Yes

No

Have personal liability insurance for use of said vehicle in amount of the amount recommended by CHC/SEIA insurer?*

Yes

No

Valid copy of vehicle registration?*

Yes

No

Proof of legal age to drive?*

Yes

No

Authorization for DMV verification and meets legal and insurance carrier requirements?*

Yes

No

Are you on lay-off and subject to recall?*

Yes

No

Are you legally eligible for employment in this country (proof of legal ability to work in the U.S. will be required per federal law, within three days of the date of hire)?*

Yes

No

Have you ever been employed by CHC/SEIA?*

Yes

No

Do you have any relative currently working for CHC/SEIA? If so, please list name and current department:*

YesYes

No

If you are under 16, can you furnish a work permit?*

Yes

No

Not Applicable

Have you ever been *convicted of a criminal or military offense? If so, please explain facts and include dates:*

YesYes

No

* Please note that a conviction record is not a bar to employment with CHC/SEIA, although failure totruthfully respond to this question could bar employment with CHC/SEIA. Factors such as the age of theevent, seriousness and nature of the violation, relevancy of the violation to the position being applied forand rehabilitation efforts will be considered in hiring decisions involving previous convictions.

Have you ever been excluded or disbarred from participation by CMS, Medicare, Medicaid, and/or other Federal health care programs?*

Yes

No

References

Please list references that CHC/SEIA may check. It would be helpful if you could notify references and indicate to them that a CHC/SEIA representative will be calling. CHC/SEIA would like the contact to be able to provide information related to your performance, attendance, co-worker skills, and expertise. Please authorize the individual to release this information.

Professional Reference Name:*

Your Association With Reference:*

Company Name:*

Company Address:*

City/State/Zip*

Phone Number:*

E-mail Address*

Professional Reference Name:

Your Association With Reference:

Company Name:

Company Address:

City/State/Zip

Phone Number:

E-mail Address

Professional Reference Name:

Your Association With Reference:

Company Name:

Company Address:

City/State/Zip

Phone Number:

E-mail Address

Signature

Clear

CHC/SEIA is an AFFIRMATIVE ACTION / EQUAL OPPORTUNITY EMPLOYER. CHC/SEIA will consider all applicants without regard to race, religion, color, sex (including pregnancy, gender identity, and sexual orientation), marital status, parental status, national origin, age, disability, family medical history or genetic information, political affiliation, military service, other non-merit based factors, or other legally protected classification. No question on this form is intended to secure information to be used for such discrimination. CHC/SEIA will give this application every consideration. However, in accepting it, CHC/SEIA makes no commitment of employment to the applicant. Terms and Conditions:1) Employment at will. I understand that this application for employment and any other CHC/SEIA documents are not contracts of employment, and that any person who is hired may voluntarily leave their employment upon giving proper notice, and may be terminated by CHC/SEIA at any time for any reason. I understand that any oral or written statements to the contrary are hereby expressly disavowed and should not be relied upon by a prospective or existing employee ( with the exception of contract employees - physicians and dentists who do have written contracts).2) In the event this application results in employment with CHC/SEIA, you will be expected to comply with the rules and regulations established by CHC/SEIA.3) By my signature, I hereby certify that all of the answers and statements are true and complete. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I understand that falsification or omission of any information can disqualify me from being hired for employment, or once hired, can be cause for termination.I hereby authorize Community Health Centers of Southeastern Iowa, Inc. (CHC/SEIA) to request and receive employment reference and verification information. Reference information may include, but is not limited to: prior employment history; military service; educational credentials and professional/personal character references. Sources of verification may include, but are not limited to, individual representatives from companies, corporations, partnerships or associations (prior employers or contractors); law enforcement agencies; military agencies; licensing agencies; schools; colleges or universities, Department of Motor Vehicles (DMV), etc.A criminal background check will be completed for applicants prior to an offer of employment with CHC/SEIA. CHC/SEIA reserves the right to contract for background check services. I authorize the above-mentioned entities to furnish any and all information necessary for CHC/SEIA to complete verification of my prior employment and assess my suitability for the position. I further release CHC/SEIA and their affiliates and subsidiaries from any and all liability and responsibility arising out of the release of any such employment verification information.

Date

Resume/Cover Leter*

Maximum file size: 157.29MB

Attach resume and cover letter.

Date

Employment Application

Employment History

Educational Background

Professional Certifications and Licensures:

For Clerical Applicants:

Additional Information:

References