Application for Employment

Employment Application

Primary Care Providers for a Healthy Feliciana, PCPFHF, dba RKM Primary Care is an equal opportunity employer for all individuals without regard to a person's race, color, religion, sex (including pregnancy, gender status and sexual orientation), national origin, age (40 or older), disability or genetic information, or any other category protected by applicable federal, state or local laws.
Position Applied For:*
Full Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
E-mail*
example@example.com
Type of employment desired:

Full TimePart TimePRN
PCPFHF dba RKM Primary Care shall not hire, in any capacity blood relatives up to and including second cousins and relatives by marriage or adoption which includes spouses and in-laws of members of the PCPFHF Board. Are you related to a board member.

YesNo
Have you previously applied for employment with this company?

YesNo
Have you ever been employed by PCPFHF?

YesNo

INSTRUCTIONS FOR ANSWERING THE NEXT TWO QUESTIONS
All applicants: Do not include convictions that were sealed, eradicated, erased, annulled by a court, or expunged, or convictions that resulted in referral to a diversion program. Criminal convictions or arrests will not automatically disqualify an applicant from a particular job. The Company will consider the nature of the crime, its seriousness, the substantial relation to the position's functions and qualifications, the number of occurrences, the applicant's age at the time of the crime, the time elapsed since the crime, the applicant's entire work and educational history, employment references and recommendations and the business necessity of any exclusion when required by law.
Have your ever pled guilty or no contest to, or been convicted of any criminal offense other than the applicable exceptions listed above?

YesNo
Have you ever initiated an act of violence in the work place?

YesNo
If yes, please provide the date(s) and explain so that individual circumstances can be considered. (A "Yes" will not necessarily disqualify you from employment.)

Name

First NameMiddle NameLast Name
Education
HIGH SCHOOL

Street Address

Name of High School

CityState / Province

Postal / Zip Code
Graduate- Yes/No?
Post High School/College/Technical School

Name of School

Street Address Line 2

CityState

Postal / Zip Code
Graduated Yes/No?
Years completed
Area of Study
Certifications
List all special technical skills that you feel qualify you for the job for which you are applying. (For example, computer skills, software, equipment operation, special tools or machines, etc.)
Licenses:

Work Experience
Please list your previous employment experience, beginning with your most recent. You may include any verifiable work performed on a volunteer basis, internships or military service.

Prior Employers may be contacted to obtain work history listed.
Have you ever been terminated or asked to resign from any job?

YesNo
Employer 1

Employer name

Street Address

CityState

Zip Code
Supervisors name:
Phone Number

Area CodePhone Number
Job Title:
Year Started Employment
Year Left Employment
Duties:
Reason for Leaving
Employer 2

Employer name

Street Address

CityState

Zip Code
Supervisors name:
Phone Number

Area CodePhone Number
Job Title:
Year Left Employment
Year Started Employment
Duties:
Reason for Leaving
Employer 3

Employer name

Street Address

CityState

Zip Code
Supervisors name:
Phone Number

Area CodePhone Number
Job Title:
Year Started Employment
Year Left Employment
Duties:
Reason for Leaving

Name*

First NameMiddle NameLast Name
References
Reference 1

Name

Street Address

EmployerJob Title

Postal / Zip Code
Email
example@example.com
Phone Number

Area CodePhone Number
Reference 2

Name

Street Address

EmployerJob Title

Postal / Zip Code
Email
example@example.com
Phone Number

Area CodePhone Number
Reference 3

Name

Street Address

EmployerJob Title

Postal / Zip Code
Email
example@example.com
Phone Number

Area CodePhone Number
Duties:
Name

First NameMiddle NameLast Name
Applicant Certification
All of the requirements below are in accordance to applicable federal, state, and local law and PCPFHF policies/procedures:

* I understand and agree that if driving is a requirement of the job for which I am applying, my employment and/or continued employment is contingent on possessing a valid driver’s license.

* I understand that the PCPFHF is a drug-free workplace. In compliance with the Drug-Free Workplace Act of 1988, PCPFHF has a commitment to provide a safe, quality oriented and productive work environment. This statement of policy prohibits the unlawful manufacture, distribution, dispensation, possession, or use of a controlled substance by any employee during work hours or at any time while on Company premises or business. I further understand that as a condition of employment, I will abide by the drug and alcohol policy of PCPFHF with can include drug testing prior to employment, random or reasonable suspicion testing. I understand that PCPFHF may use the services of other individuals and entities in connection with the testing procedures and I agree to fully complete all required forms or documents for testing. I understand and agree that information, including the results of such tests, may (to the extent and in the manner allowed by law), be disclosed to and known by such individuals and entities.
Furthermore, I understand that it is my duty to notify PCPFHF of any criminal drug statute conviction for a violation occurring in the workplace no later than 5 days after such conviction. Employee sanctions and remedies will be followed as designated in 41 USC Ch. 81: DRUG-FREE WORKPLACE.

* If employed, I understand and agree that PCPFHF may exercise its right, without prior warning or notice, to conduct investigations of property (including, but not limited to, files, lockers, desks, vehicles, and computers) and, in certain circumstances, my personal property.

* I understand and agree that as a condition of employment, I may be required to sign confidentiality, restrictive covenant, and/or conflict of interest statement, as well as an agreement to arbitrate.

* If hired, I agree to conform to the policies and procedures of PCPFHF, and I understand that PCPFHF has discretion to modify such policies and procedures, at any time

PCPFHF IS AN AT-WILL EMPLOYER AS ALLOWED BY APPLICABLE LAW. THIS MEANS THAT REGARDLESS OF ANY PROVISION IN THIS APPLICATION, IF HIRED, THE COMPANY OR I MAY TERMINATE THE EMPLOYMENT RELATIONSHIP AT ANY TIME, FOR ANY REASON, WITH OR WITHOUT CAUSE OR NOTICE. NOTHING IN THIS APPLICATION OR IN ANY DOCUMENT OR STATEMENT, WRITTEN OR ORAL, SHALL LIMIT THE RIGHT TO TERMINATE EMPLOYMENT AT-WILL. NO OFFICER, EMPLOYEE OR REPRESENTATIVE OF THE COMPANY IS AUTHORIZED TO ENTER INTO AN AGREEMENT—EXPRESS OR IMPLIED—WITH ME OR ANY APPLICANT FOR EMPLOYMENT FOR A SPECIFIED PERIOD OF TIME UNLESS SUCH AN AGREEMENT IS IN A WRITTEN CONTRACT SIGNED BY THE CEO OF PCPFHF.

* I authorize PCPFHF or its agents to confirm all statements contained in this application and/or résumé as it relates to the position I am seeking. I agree to complete any requisite authorization forms for the background investigation.
* I authorize and consent to, without reservation, any party or agency contacted by this employer to furnish the above-mentioned information. I hereby release, discharge, and hold harmless, any party delivering information to PCPFHF or its duly authorized representative pursuant to this authorization, from any liability, claims, charges, or causes of action which I may have as a result of the delivery or disclosure of the above requested information. I hereby release from liability PCPFHF and its representative for seeking such information and all other persons, corporations, or organizations furnishing such information.
* If hired by PCPFHF, I understand that I will be required to provide genuine documentation establishing my identity and eligibility to be legally employed in the United States. I also understand that PCPFHF employs only individuals who are legally eligible to work in the United States.

THIS APPLICATION WILL BE CONSIDERED ACTIVE FOR A PERIOD OF ONE YEAR. IF YOU WISH TO BE CONSIDERED FOR EMPLOYMENT AFTER THAT TIME, YOU MUST REAPPLY.

* I certify that all information on this application, my résumé, or any supporting documents I present during any interview is and will be complete and accurate to the best of my knowledge. I understand that any falsification, misrepresentation, or omission of any information may result in disqualification from consideration for employment or, if employed, disciplinary action, up to and including immediate dismissal.
Applicant's Signature
Date

MonthDayYear
If the applicant is a minor, the foregoing release and consent must be signed by the applicant’s parent or legal guardian. Signature by the applicant’s parent or legal guardian constitutes acknowledgement by the applicant and the parent or legal guardian that PCPFHF, to the extent permitted by federal, state, and local law, can test the applicant for illegal or controlled substances, conduct inspections of property without notice, and communicate test results to PCPFHF personnel who need to know, the applicant, and the applicant’s legal guardian.
Parent or legal guardian

First NameMiddle IntitialLast Name
Witness:

First NameLast Name
Date

MonthDayYear
Should be Empty:

Employment Application

Education

Work Experience

References

Applicant Certification