Employment Application

Employment Application

Please enter a time to the nearest half hour.
Street Address
Street 2 (Apartment, P.O. Box, etc)
Please enter a street address where you can be reached.

Employment History

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

Educational Background

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

Professional Certifications and Licensures:

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
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)
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:

Additional Information:

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


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.
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.

Maximum file size: 157.29MB

Attach resume and cover letter.