REV 417 HRCHC IS AN EQUAL OPPORTUNITY EMPLOYER WWWHEALTHREACHCHCOR - PDF document

1 4 4 4 4 4 4 4 4 4 4 4 4 REV 4/17 HRCHC
4 4 4 4 4 4 4 4 4 4 4 4 REV 4/17 HRCHC IS AN EQUAL OPPORTUNITY EMPLOYER WWW.HEALTHREACHCHC.ORG We conside applicants for all positions without regard to race, color, se Last Name First Name Middle Name Address City State Zip Code Telephone Number(s) Email Address Community Health CentersBest bAa9: ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ th^LTLhb: ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ DAT9: ͺͺͺͺͺͬͺͺͺͺͺͬͺͺͺͺͺ How did you learn about us? If Website - which one? ________________ If Advertisement- which publication? ________________________________ ee referral Friend Relative REV 4/17 HRCHC IS AN EQUAL OPPORTUNITY EMPLOYER WWW.HEALTHREACHCHC.ORG EDUCATION Name Phone#Name Phone#Name Phone# of SchoolCourse of StudyYear of DegreeSchoolUndergraduateCollegeGraduate CollegeTraining, Apprenticeship,Extra-curricular Diploma/Degree REV 4/17 HRCHC IS AN EQUAL OPPORTUNITY EMPLOYER WWW.HEALTHREACHCHC.ORG 1. Employer Dates Employed From ToWork Performed Address Telephone Number(s) Hourly Rate/Salary Starting Final Job Title Supervisor May We contact? Reason for leaving 2. Employer Dates Employed From ToWork Performed Address Telephone Number(s) Hourly Rate/Salary Starting Final Job Title Supervisor May We contact? Reason for leaving 3. Employer Dates Employed From ToWork Performed Address Telephone Number(s) Hourly Rate/Salary Starting Final Job Title Supervisor May We contact? Reason for leaving 4. Employer Dates Employed From ToWork Performed Address Telephone Number(s) Hourly Rate/Salary Start

2 ing Final Job Title Supervi
ing Final Job Title Supervisor May We contact? Reason for leaving Please explain any period of time you were not working_________ REV 4/17 HRCHC IS AN EQUAL OPPORTUNITY EMPLOYER WWW.HEALTHREACHCHC.ORG Do you type? No WPM __________ Working knowledge of computer software? Yes No If yes, what programs? EHR Which Program? __________ __________________ _________________ Word Beginner Intermediate Advanced MS Excel Beginner Intermediate Advanced MS PowerPoint Beginner Intermediate Advanced MS Access Beginner Intermediate Advanced Adobe Beginner Intermediate Advanced Other Clinical Skills: RN/LPN/MA please check areas in which you have experience/certification BCLS Physician Office Practice Pediatrics Professional MembershipsSpecial skills applicable to the job for which you have appliedyou operateList other jobrelated skills, including medical procedures you are REV 4/17 HRCHC IS AN EQUAL OPPORTUNITY EMPLOYER WWW.HEALTHREACHCHC.ORG (If licensedhealth care dental provider)Professional LicensureState/License No.Date/Year IssuedTemporary revoked, suspended placed conditions upon your professional license(s)? Yes No yes,pleaseexplain and outcomeyou ever been investigated by, sanctioned by, or otherwise had your ability to participate as a provider Medicaid, Medicare or other government sponsored program, been suspended, Yes No N/ yes,explain and outcomeOTHER REQUIRED INFORMATIONHave you ever been terminated fromprevious position? yes describe:everconvictediltypleadnolocharged Yes If yes, describe_________________________________________________________________________everhadcomplaintclientmisappropriationproperty? ___________________________________________________________dismissal if hired. REV 4/17 HRCHC IS AN EQUAL OPPORTUNITY EMPL

3 OYER WWW.HEALTHREACHCHC.ORG I certify t
OYER WWW.HEALTHREACHCHC.ORG 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 4D 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 under- stood that this "at will" employment relationship may not be changed by any written document or by conduct unless such 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.Signature of Applicant Note to Applicants: DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING.Are you capable of performing in a reasonable manner, with or without a reasonable accommodation, the activities involved in the job or occupation for which you have applied? A review of the activities involved in such a job or occupation has been provided. HealthReach Community Health Centers10 Water Street, Suite 305Waterville, Maine 04901207-872-5610 or Toll free in Maine 1-800-299-2460 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 HRCHC IS AN EQUAL OPPORTUNI

4 TY EMPLOYER WWW.HEALTHREACHCHC.ORG I ce
TY EMPLOYER WWW.HEALTHREACHCHC.ORG 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 4D 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 under- stood that this "at will" employment relationship may not be changed by any written document or by conduct unless such 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.Signature of Applicant Note to Applicants: DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING.Are you capable of performing in a reasonable manner, with or without a reasonable accommodation, the activities involved in the job or occupation for which you have applied? A review of the activities involved in such a job or occupation has been provided. HealthReach Community Health Centers10 Water Street, Suite 305Waterville, Maine 04901207-872-5610 or Toll free in Maine 1-800-299-2460 HRCHC IS AN EQUAL OPPORTUNITY EMPLOYER WWW.HEALTHREACHCHC.ORG (If l

5 icensedhealth care dental provider)Profe
icensedhealth care dental provider)Professional LicensureState/License No.Date/Year IssuedTemporary revoked, suspended placed conditions upon your professional license(s)? Yes No yes,pleaseexplain and outcomeyou ever been investigated by, sanctioned by, or otherwise had your ability to participate as a provider Medicaid, Medicare or other government sponsored program, been suspended, Yes No N/ yes,explain and outcomeOTHER REQUIRED INFORMATIONHave you ever been terminated fromprevious position? yes describe:everconvictediltypleadnolocharged Yes If yes, describe_________________________________________________________________________everhadcomplaintclientmisappropriationproperty? ___________________________________________________________dismissal if hired. HRCHC IS AN EQUAL OPPORTUNITY EMPLOYER WWW.HEALTHREACHCHC.ORG Do you type? No WPM __________ Working knowledge of computer software? Yes No If yes, what programs? EHR Which Program? __________ __________________ _________________ WordIntermediateAdvancedMS Excel Beginner Intermediate Advanced MS PowerPoint Beginner Intermediate Advanced MS Access Beginner Intermediate Advanced AdobeBeginnerIntermediateAdvancedOther Clinical Skills: RN/LPN/MA please check areas in which you have experience/certification BCLS Physician Office Practice Pediatrics Professional MembershipsSpecial skills applicable to the job for which you have appliedyou operateList other jobrelated skills, including medical procedures you are REV 4/17 HRCHC IS AN EQUAL OPPORTUNITY EMPLOYER WWW.HEALTHREACHCHC.ORG Employ Dates Employed From ToWork Performed dress hone Number(s) pervisor May We contact? Reason for leaving Employ Dates Employed From ToWork Performed dress hone Number(s) pervisor May We contact? Reason for leaving Employ Dates Employed Fro

6 m ToWork Performed dress hon
m ToWork Performed dress hone Number(s) pervisor May We contact? Reason for leaving Employ Dates Employed From ToWork Performed dress hone Number(s) pervisor May We contact? Reason for leaving Please explain any period of time you were not working_________ HRCHC IS AN EQUAL OPPORTUNITY EMPLOYER WWW.HEALTHREACHCHC.ORG EDUCATION Name Phone#amePhone#Name Phone# of SchoolCourse of StudyYear of DegreeSchoolUndergraduateCollegeGraduate CollegeTraining, Apprenticeship,Extra-curricular Diploma/Degree HRCHC IS AN EQUAL OPPORTUNITY EMPLOYER WWW.HEALTHREACHCHC.ORG We conside applicants for all positions without regard to race, color, sex, age, national or Last Name First Name Middle Name Address City State Zip Code Telephone Number(s) Email Address Community Health CentersBest is: ____________a.m. or __________p.m.If you are under 18 years of age, can you provide required proof of your eligibility to work? Are you authorized to work in the United States?Have you ever filed an application with us before?If yes, give date _____________Have you ever been employed with us before?If yes, give date _____________Do any of your friends or relatives work here? Are you currently employed? May we contact your present employer?Date available to work What is your desired salary range? ________ Yes No No Yes No Are you availablework:Can you travel if a job requires it?Full-timePer DiemPart-time (please indicate Mornings Afternoons Evenings)Temporary(pleaseindicateavailable_/_/_ bAa9: ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ th^LTLhb: ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ DAT9: ͺͺͺͺͺͬͺͺͺͺͺͬͺͺͺͺͺ How did you learn about us? If Website - which one? ________________ If Advertisement- which publication? ________________________________ ee referral Friend Relative