APPLICATION FOR EMPLOYMENT

Neighborhood Health Clinics, Inc. PO Box 11949, 1717 S. Calhoun Street Fort Wayne, IN 46862-1949

We consider applicants for all positions without regard to race, color, religion, sex, sexual orientation, national origin, age, marital or veteran status, or the presence of a non-job-related medical condition or handicap.

PLEASE PRINT OR TYPE ALL RESPONSES

Date of Application

Date

Position applied for

Last

First

Middle

Street

City

State

Zip Code

Phone

Email address

example@example.com

Have you filed an application here before?

If Yes please give date

Date

If Yes by whom

May we contact your present employer?

Email address

example@example.com

If you are under 18 years of age, can you furnish a work permit?

Are you legally eligible for employment in the United States? (Proof of citizenship or immigration status will be required upon employment)

On what date would you be available for work?

Have you ever been discharged from employment?

If yes please explain

Are you on lay-off and subject to recall?

YesNo* Can you travel if the job requires it?

Graduate School Vocational School

List any memberships in professional, trade, business, or civic organizations and / or office held. (You may exclude memberships that would reveal race, color, religion, sex, sexual orientation, national origin, age, ancestry, or handicap)

List any memberships in professional trade or office held You may exclude memberships that would reveal race color religion sex sexual orientation national origin age ancestry or handicap

List special training or skills that would be of special benefit in the job for which you are applying

Indicate any languages you speak, read, and / or write. Speak Language

Do you currently hold any professional licenses?

If Yes, complete following: Registration #

Give name, e-mail address, and phone # of 3 references who are not related to you. At least 2 should be previous employers.

Reference

EMPLOYMENT EXPERIENCE: Start with your present or last employer. Include military service assignments and volunteer activities. (You may exclude memberships that would reveal race, color, religion, sex, sexual orientation, national origin, age, ancestry, or handicap)

Employer

Address

Phone

Job Title

Supervisor

Reason for Leaving

from

to

Start

Employer

Address

Phone

Job Title

Supervisor

Reason for Leaving

from

to

Start

Final

Employer

Address

Phone

Job Title

Supervisor

Reason for Leaving

from

to

Start

Final

Work Performed

Employer

Address

Phone

Job Title

Supervisor

Reason for Leaving

from

to

Have you ever been convicted of, pled guilty or no contest to, been imprisoned, or on probation or parole for any misdemeanor or felony?

If yes please explain

Have you ever been convicted of a controlled substance violation, healthcare fraud or patient abuse violation?

If yes please explain

Have you been excluded from participating in the Medicare, Medicaid or other federal programs?

If yes please explain

Have you ever had any action taken against your professional licensure? YesNoN/A

If yes please explain

Are you a high school graduate or do you have the equivalent GED?

Are you capable of demonstrating commitment to service excellence?

Are you capable of successfully passing a criminal background check?

If yes please list approximate dates

Date

Are you a veteran of the U.S. Military Services?

If Yes what branch

I certify that answers given herein are true and complete to the best of my knowledge.

In applying for employment, I want Neighborhood Health Clinics, Inc. (NHCI) to be fully informed of my work history. I, therefore, authorize NHCI to investigate my background and obtain any and all information that may concern me. I release all persons, including NHCI, schools, companies, corporations, and law enforcement agencies from any liability as a result of furnishing such information.

I fully understand that, if employed, any misrepresentation of acts on my application is sufficient reason for my termination. In addition to my authorization and release of information and entities set forth above,I authorize NHCI to discuss the results of any pre-employment investigation with persons who conduct the interview(s) in any investigation as well as with those individuals responsible for hiring. | understand that nothing contained in my application, or in the granting of, or conducting of, an interview is intended to create an employment contract or binding contractual relationship between NHCI and me either for employment or for the providing of any benefit. No promises regarding employment or duration of employment have been made to me, and I understand that no such promises or guarantees are binding upon NHCI unless made in writing by the President/CEO or his/her designee.

If an employment relationship is established, I understand that I have the right to terminate my employment at any time, with or without notice, and for any lawful reason or cause. If any employment relationship is established, in consideration of such an employment relationship, I agree not to use or reveal any confidential information of NHCI.

NHCI and its directors, officers, administrators, managers, employees, and agents are all released by me from any legal responsibility or liability for the release of such information and records as authorized above or any other liability that may arise from the release of such information.

I have read the above statement carefully, and | agree to abide by all of the terms set forth above.

Applicant Signature

Date

This application for employment shall be considered active for a period of time not to exceed 180 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether applications are being accepted at that time.