Employment Application

Items in red are required.

Position Applied For
Salary Desired
Position

Personal Information

First Name
Middle Name
Last Name
Phone
Email
Address
City
State
Zip

Education

What is the highest level of education have you completed? If college, what is your degree
List any specialized training, skills, or abilities not covered by your employment history that would be helpful if you are employed at Promise Community Health Center.
Indicate any languages other than English you can speak, read, and/or write

Licensure Information

Where did you receive your professional training?

Dates of professional training

From (mm/yyyy)      To (mm/yyyy)
Place of registration/licensure

License number

License status

Employment History

Are you currently employed?

Current Employer (or most recent employer)

Employer Name
Type of Business
Employer Phone

Address
City
State
Zip
Date of Employment
From (mm/yyyy)      To (mm/yyyy)
Exact Title of Your Position:
Name & Title of Your Immediate Supervisor
May we contact this employer
Description of duties, responsibilities and equipment operated
Liked Most About Job


Liked Least About Job

Final Pay $    Per 
Reason for Leaving

Previous Employer 1

Employer Name
Type of Business
Employer Phone

Address
City
State
Zip
Date of Employment
From (mm/yyyy)      To (mm/yyyy)
Exact Title of Your Position:
Name & Title of Your Immediate Supervisor
May we contact this employer
Description of duties, responsibilities and equipment operated
Liked Most About Job


Liked Least About Job

Final Pay $    Per 
Reason for Leaving

Previous Employer 2

Employer Name
Type of Business
Employer Phone

Address
City
State
Zip
Date of Employment
From (mm/yyyy)      To (mm/yyyy)
Exact Title of Your Position:
Name & Title of Your Immediate Supervisor
May we contact this employer
Description of duties, responsibilities and equipment operated
Liked Most About Job


Liked Least About Job

Final Pay $    Per 
Reason for Leaving

Previous Employer 3

Employer Name
Type of Business
Employer Phone

Address
City
State
Zip
Date of Employment
From (mm/yyyy)      To (mm/yyyy)
Exact Title of Your Position:
Name & Title of Your Immediate Supervisor
May we contact this employer
Description of duties, responsibilities and equipment operated
Liked Most About Job


Liked Least About Job

Final Pay $    Per 
Reason for Leaving

Check All That Apply

Are you legally eligible to work in the U.S.A? On what date would you be available to work?
/ / (mm/dd/yyyy)
Are you available to work?



What days are you available to work?





Do you know anyone who currently works for Promise Community Health Center?
If yes, who? Relationship:
Have you previously worked for Promise Community Health Center?
Have you been convicted of a felony?
(Conviction will not necessarily disqualify an applicant from employment.)
If yes, please explain where, when, and disposition of case:   
Have you served in the U.S. Armed Forces or National Guard?
Describe your experience:
Do you have a valid driver's license?
If yes, state issued: License Number:
Give dates of any driver's license suspensions:
Do you have reliable transportation?

Professional References

Reference ONE Name
Title
Phone Number
Describe Your Relationship to this Reference
Reference TWO Name
Title
Phone Number
Describe Your Relationship to this Reference
Reference THREE Name
Title
Phone Number
Describe Your Relationship to this Reference

Optional Resume Upload

Upload Resume and optional Cover Letter. (Please submit a single PDF or Microsoft Word file)
How did you learn of this job opening?

 
 





 
 

Authorization

By checking this box and submitting this electronic application, I affirm that I have read and I agree to the conditions of the application above, and that all information I have provided in this application is correct and complete to the best of my knowledge.

Required