652 F Central Avenue
Dover, NH 03820
Today’s Date:
APPLICATION FOR EMPLOYMENT
Avis Goodwin Community Health Center is an equal opportunity employer and considers all applicants without regard to: race, color, gender, age, religion, sexual orientation, national origin, disability, veteran status, or any other classification protected by state, federal, or local law.
PLEASE READ, COMPLETE & SIGN. PLEASE BE SURE TO PRINT ALL RESPONSES
POSITION(S) DESIRED
1.
2.
3.
HOW WERE YOU REFERRED TO AGCHC?
APPLICANT’S DATA
LAST NAME
FIRST NAME
MIDDLE NAME
DATE OF BIRTH (IF UNDER 18)
ADDRESS NO. AND STREET
CITY STATE ZIP
PHONE
SOCIAL SECURITY NUMBER
IF NOT A U.S. CITIZEN, ARE YOU LEGALLY ELIGIBLE TO WORK IN THE U.S.? YES NO
E-MAIL ADDRESS
**Completion of a Form I-9 and proof of identity and eligibility will be required as a condition of employment upon hire.
CATEGORY OF WORK (Circle all that apply)
FULL TIME PART TIME TEMPORARY SUMMER PER DIEM
WHAT DAYS CAN YOU WORK?
WHAT HOURS CAN YOU WORK?
IF A VETERAN, DATE AND TYPE OF DISCHARGE
EDUCATION
NAME OF HIGH SCHOOL LAST ATTENDED
NAME OF MOST RECENT COLLEGE, TECHNICAL, TRADE OR OTHER SCHOOL
ADDRESS:
CITY, STATE, ZIP
MAJOR COURSE OF STUDY
DEGREE OR DIPLOMA GRANTED DATE
FOR NURSES ONLY:
CURRENT NEW HAMPSHIRE NURSING LICENSE NUMBER: EXPIRATION DATE:
SKILLS
PLEASE LIST ANY SPECIAL KNOWLEDGE, SKILLS AND/OR QUALIFICATIONS RELATED TO THE POSITION FOR WHICH YOU ARE APPLYING (FOR EXAMPLE, IF YOU ARE APPLYING FOR AN ADMINISTRATIVE POSITION, PLEASE LIST SOFTWARE PACKAGES WITH WHICH YOU ARE PROFICIENT):
EMPLOYMENT HISTORY: PLEASE PROVIDE AN ACCURATE AND COMPLETE EMPLOYMENT HISTORY. List all positions starting with your present or most recent position. If this information is already on your resume, please attach your resume and list only those items not listed on your resume (e.g. supervisor, reason for leaving, etc.).
EMPLOYER’S NAME
ADDRESS
FROM
TO
SUPERVISOR
POSITION/DUTIES
REASON FOR LEAVING
1
MO/YR
Telephone
Zip
Salary (Weekly)
2
3
4
..
5
Attach additional sheet if necessary. Note: ALL PREVIOUS EMPLOYERS MAY BE CONTACTED FOR REFERENCE INFORMATION
MAY WE CONTACT YOUR PRESENTEMPLOYER FOR A REFERENCE AT THIS TIME? YES NO
If not, please explain why:
1. Have you ever been convicted of abuse, neglect, and/or exploitation of any person or have you been convicted of misappropriation of funds or property? Yes No If yes, please describe in full
2. Have you ever been convicted of a crime that has not been annulled by a court? Yes No If yes, please describe in full
(Note: A criminal conviction will not necessarily disqualify you from employment. Depending upon the position for which you are applying, any offer of employment may be conditioned upon your consent to and satisfactory results of a criminal record check.)
3. Do you have any relatives working at AGCHC or on our Board of Directors? ™ Yes ™ No
If yes, please list name and relationship
CERTIFICATION AND AUTHORIZATION OF APPLICANT
I certify that all the above information (and resume, if applicable) is true and complete. I understand that any misrepresentation or omission may result in my disqualification from further consideration for employment and/or my termination from employment.
Further, in order that Avis Goodwin Community Health Center (“AGCHC”) may process my application for employment, I hereby authorize AGCHC and its parents, affiliates, subsidiaries, officers, directors, employees, representatives, and agents (hereinafter collectively referred to as “AGCHC”) to conduct a complete investigation into my background including, but not limited to, my entire employment history, including my fitness for duty at all prior employment; education history; criminal record and military record, if any; to obtain opinions and references regarding my moral character and reputation and to solicit and obtain any other information AGCHC, in its sole discretion, deems as necessary to determine my eligibility for employment or for the purposes of confirming the accuracy or completeness of any information I have provided to AGCHC.
In consideration for the processing of my application for employment with Avis Goodwin Community Health Center, I hereby RELEASE, INDEMNIFY, AND HOLD HARMLESS AGCHC and all previous employers and other persons and organizations furnishing information in connection with AGCHC’s investigation into my background from any and all liability based on their authorized receipt, disclosure, and use of the information gathered in processing my application for employment with AGCHC.
I understand that, if hired, any offer is contingent upon production of proof of employment eligibility and the completion of a Form I-9, a satisfactory criminal background records check and, depending on the position for which I am hired, my submission to a post-offer drug test and medical examination to determine my ability to perform the essential functions of the position offered. I also understand that if offered a position I will be an employee at-will.
Print Name Signature
Rev. 12/6/05
Date