* Are you legally eligible to be employed in the United States? (Proof of identity and eligibility will be required of all incoming employees):

Yes   No

* Are you at least 18 years of age or older? (If no, you may be required to provide authorization to work):

Yes   No

* Have you ever been excluded or suspended from any federally-funded government health care program, including Medicare or Medicaid or convicted of any healthcare related crime? A conviction will not necessarily disqualify an applicant from employment.:

Yes   No

If Yes, please explain:

* Do you or a member of your immediate family hold an ownership interest in any health-care or related business, either directly or indirectly?:

Yes   No

If Yes, please explain:

If Yes, has that business ever been suspended, excluded or debarred from any federally-funded health care program, including Medicare or Medicaid?:

Yes   No

* Do you have any relatives or Board Members that currently work at PVCHC?:

Yes   No

If so, what Department?:

HR/Recruitment Finance Other

If Other, please specify:

* Have you ever been employed, worked, volunteered, or completed clinical requirements as a student for this Company before?:

Yes   No

If Yes, provide details (dates, department, position):

* Are you participating in a scholarship or loan repayment program which requires you to fulfill a service commitment in a community health center or a similar organization? (Example, NHSC loan repayment program).:

Yes   No

If Yes, which one:

* Are you bilingual?:

Yes   No

If so, what language(s):

* Where did you hear about the job opening?:

Job BoardJob FairCollegeFriendReferral by PVCHC EmployeeOther

If you selected College, Referred by a PVCHC Employee,  or Other, please provide more details (Name, etc).:

* Salary desired:

* Have you ever been involuntarily separated from any employment, not including a lay off?:

Yes   No

If yes, please explain::

* Would you prefer:

Full-time work    Part-time work    Per Diem work

* Are you able to perform the essential functions of the job for which you are applying, with or without a reasonable accommodation?:

Yes   No

If no, please explain:

* When would you be available to begin work?:

* Are you currently employed?:

Yes   No

If so may we inquire of your present employer?:

Yes   No

If presently employed, why are you considering leaving?:

Give record of all High Schools, Colleges, Universities and Vocational/Technical Schools you have attended. All professional positions will require proof of education prior to employment.

School Name	Did you Graduate? or number of years complete	Degree Received	Subjects/Major
*	*	*	*

List any business or clinical skills you have that are related to the position for which you have applied.:

* Licenses or Certificates (give type of license or certification):

* License#:

Have you ever had a professional license suspended or revoked for any reason?:

Yes   No

If yes, please explain::

Expiration Date:

Is this licensure/certification all current and without restriction?:

Yes   No

Have you ever received a letter of admonition regarding your license?:

Yes   No

If yes, please explain::

Give your full employment record, starting with your current or most recent employment. Please do not state "See Resume". Complete the employment information completely.

* Start Date:

* End Date:

* Employer Name:

* Employer Phone:

* Job Title:

* Supervisor Name:

* Supervisor Title:

* Duties:

* Reason for Leaving:

Start Date:

End Date:

Employer Name:

Employer Phone:

Job Title:

Supervisor Name:

Supervisor Title:

Duties:

Reason for Leaving:

Start Date:

End Date:

Employer Name:

Employer Phone:

Job Title:

Supervisor Name:

Supervisor Title:

Duties:

Reason for Leaving:

Name	Company	Relationship	Phone Number
*	*	*	*
*	*	*	*
*	*	*	*

AN EQUAL OPPORTUNITY EMPLOYER

We do not discriminate on the basis of race, color, religion, national origin, sex, age, disability, genetic information or any other status protected by law or regulation. It is our intention that all qualified applicants be given equal opportunity and that selection decisions are based on job-related factors.

JOB APPLICATION DISCLAIMER AND ACKNOWLEDGEMENT:

I certify that the information contained in this application is complete, true, and correct and authorize the Company to research and verify my responses. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date. The typing of my name will be considered as legally binding as an ink signature.

I authorize the investigation of any or all statements contained in my application. I also authorize, whether listed or not, any person, school, current employer, past employers and organizations to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements.

I understand that any offer of employment by Peak Vista Community Health Centers will be contingent upon the results of background checks and TB test /chest x-ray.

I understand that the Immigration Reform and Control Act of November 6, 1986 requires me to prove the legality of my residency or citizenship. I am also aware that the failure to provide such proof at the time of request may legally force my termination

I also acknowledge that my employment may be terminated, or any offer or acceptance of employment withdrawn, at any time, with or without cause, and with or without prior notice at the option of the company or myself.

I UNDERSTAND THAT THIS APPLICATION, VERBAL STATEMENTS BY MANAGEMENT, OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE AN EXPRESS OR IMPLIED CONTRACT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. ONLY THE PRESIDENT OF THE ORGANIZATION HAS THE AUTHORITY TO ENTER INTO AN AGREEMENT OF EMPLOYMENT FOR ANY SPECIFIED PERIOD AND SUCH AGREEMENT MUST BE IN WRITING, SIGNED BY THE PRESIDENT (OR AUTHORIZED COMPANY EXECUTIVE) AND THE EMPLOYEE. IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME, WITH OR WITHOUT REASON AND WITH OR WITHOUT NOTICE.

* Signature (type name):

* Date: