Application for Employment
First Care Health Center is an equal opportunity employer and does not discriminate on the basis of gender, age, race, color, religious creed, marital status, national origin, ancestry, disability or handicap in employment or the provisions of services.
Personal Information
Date of Application:
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Month
-
Day
Year
Date
Name:
First Middle Last
Address:
Street, Apartment No., City, State, Zip Code
Telephone: (Home)
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Area Code
Phone Number
Telephone: (Cell)
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Area Code
Phone Number
Best time/phone number to contact you is:
Email:
example@example.com
Are you prevented from lawfully becoming employed in the United States because of Visa or Immigration Status? Proof of citizenship or immigration status will be required upon employment.
Yes
No
Position applied for:
If less than 18 years of age, can you provide required proof of your eligibility to work?
Yes
No
Haveyou ever filed an application with us before?
Yes
No
If you answered "yes" to the question above, please select date when you completed a previous application with us.
-
Month
-
Day
Year
Date
Have you ever been employed with us before?
Yes
No
If you answered "yes" to the question above, please select date when you completed a previous application with us.
-
Month
-
Day
Year
Date
Are you currently employed?
Yes
No
May we contact your present employer?
Yes
No
Have you ever been convicted of a felony?
Yes
No
Have you ever been excluded from participation in any federally funded health care programs?
Yes
No
Date available for work
-
Month
-
Day
Year
Date
What is your desired salary range?
What is your desired salary range?
Full Time
Flex Position
Part Time
Temporary Position
Can you travel if the job requires it?
Yes
No
How did you hear about this position?
Education
Name and Address of School
Course of Study
Years Completed
Diploma/Degree
High School
Undergraduate College
Graduate/Professional
Other (Specify)
Describe any specialized training (e.g. CPR, ACLS, PALS, IV Certification), apprenticeship, skills, ongoing training/education, and extra-curricular activities.
Work Experience
Start with your present or last job. Include any job related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, nation origin, disabilities or other protected status. Please include all positions held within each organization.
Employer
Address, Telephone Number
Date Employed
From - To
Starting/Present Job Title
Hourly Rate/Salary
Starting - Final
Supervisor
Reason For Leaving
Work Performed
Employer
Address, Telephone Number
Date Employed
From - To
Starting/Present Job Title
Hourly Rate/Salary
Starting - Final
Supervisor
Reason For Leaving
Work Performed
Employer
Address, Telephone Number
Date Employed
From - To
Starting/Present Job Title
Hourly Rate/Salary
Starting - Final
Supervisor
Reason For Leaving
Work Performed
PERSONAL/PROFESSIONAL REFERENCES (Do not include family members or past supervisors)
Name
Phone Number
Best Time to Call
Occupation
1
2
3
I certify that answers given herein 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. This application for employment shall be considered active for a period of time not to exceed 30 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an “at will” nature, which means that the Employee may resign at any time and the Employer; may discharge Employee at any time with or without cause. It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such is change is specifically acknowledged in writing by an authorized executive of this organization. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.
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Compliance Program Questionnaire
Have you ever been convicted of a crime which is listed as grounds for mandatory or permissive exclusion from any Federal or State healthcare program pursuant to42 U.S.C & 1320a-7(a)-(b)(3) (whether you were actually excluded or not)? (For purposes of this question, “convicted” has the meaning set forth in U.S.C & 1320a-7(I) and includes any judgment of conviction that has been entered against you, even if there is an appeal pending or the judgment has been expunged; any finding of guilt by a federal, state, or local court; any plea of guilty or nolo contendere; or any entry into a first offender, deferred adjudication or other program whereby a judgment of conviction has been withheld).
Yes
No
Please explain:
Have you ever been excluded, suspended or debarred from; or otherwise sanctioned byt he Medicare or Medicaid programs or any other federally funded healthcare programs?
Yes
No
Please explain:
Have you ever defaulted on a Health Education Assistance loan?
Yes
No
Please explain:
Do you, or any member of your immediate family, or household, have a direct or indirect ownership or controlling interest of 5% or more in any health care or related business? (For purposes of this question, “immediate family member” has the meaning given in 42 U.S.C & 1320a-7(J) and includes your: (1) spouse, natural or adoptive parent, child, or sibling; (2) stepparent, stepchild, stepbrother, or stepsister; (3) father, mother, daughter, son, brother, or sister-in-law; (4) grandparent or grandchild). (Include provider names for each.)
Yes
No
Please list and explain:
Have any of the entities in question #4 above, been excluded, suspended or debarred from or otherwise sanctioned by Medicare, Medicaid or any other federally funded health care programs?
Yes
No
Please explain:
Print Name
Date
Signature
Social Security No.
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Section I: To be completed by applicant.
I hereby authorize First Care Health Center to investigate my record and to ascertain any and all information that may concern my record and character. I release my present and past employers, references, educational institutions, and all persons whomsoever from any damage because of furnishing said information
Signature:
Date:
Please submit your resume in PDF format.
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Section II: To be completed by First Care Health Center:
The following individual is an applicant for a position at First Care Health Center.
Applicant Name:
Position:
As a former or present employer, we would appreciate your evaluation of this person.
You have been listed as a character reference.
Please complete Section III as applicable.
Thank you.
Signature:
Title:
Section III: To be completed by reference.
Employed from ____ to ________.
Department/Title:
Salary:
Reason for leaving:
In what capacity did you know this person:
Supervisor
Co-worker
Friend
Other: _______________________
How would you evaluate this person in efficiency?
Above Average
Average
Below Average
How would you evaluate this person in dependability?
Above Average
Average
Below Average
How would you evaluate this person in character?
Above Average
Average
Below Average
How would you evaluate this person in cooperation?
Above Average
Average
Below Average
How would you evaluate this person in job knowledge?
Above Average
Average
Below Average
Would you rehire?
Yes
No
If not, why not?
Is there any other information that might help us?
Signature:
Title:
Date:
Submit
Should be Empty: