Community Health & Dental Care, Inc.
11 Robinson St. Suite 100, Pottstown, PA 19464
Telephone: (610) 326-9460 Fax: (610) 326-2432
Employment Application
An Equal Opportunity Employer
Date of Application: ______
This application was designed for use with several positions and some questions may not be completely applicable to the position for which you are applying.
So that you will receive full consideration for opportunities at Community Health & Dental Care, Inc., please answer all questions. If information is missing, your application may be rejected. If you have a resume please transfer all relevant data to this form.
Your application will remain valid and will receive consideration for open positions for 60 days from the application date.
Personal Data
1. Name: ______Email address ______
2. Address: ______Date of Birth______
______Daytime #: ______
City______State______Zip______
3. How were you referred to us? Internet Walk In Agency School Employee Other
4: Name of referral source: ______
5. Are you over 18 years of age: Yes No
If under 18 can you, after employment, submit a work permit? Yes No
6. State name(s) of any relative(s) in our employ and your relationship to them: ______
______
7. Are you legally eligible for employment in the United States? Yes No
Note: Proof of identity and eligibility will be required upon employment.
Position Availability
1. Position desired: ______
2. Do you want to work Full Time Part Time
If part time, specify days and hours: ______
3. Are you willing to work overtime as necessary? Yes No
4. Salary desired: ______
5. Have you ever been employed with us before? Yes No
If yes, please specify position and dates: ______
Last Updated on 10/16/2018 at 4:17 PM
CHDC Employement Application -revision
Community Health & Dental Care, Inc.
11 Robinson St. Suite 100, Pottstown, PA 19464
Telephone: (610) 326-9460 Fax: (610) 326-2432
Employment History
- List below the names of your last three employers including U.S. Military Service (you may list volunteer positions as well as paid positions, if you wish). List present employer or most recent employer first.
*Employer: ______Start Date: ______End Date: ______
Address & phone#:______Reason for Leaving: ______
______Title/Nature of Work: ______
Name/Title of Immediate Supervisor: ______
*Employer: ______Start Date: ______End Date: ______
Address & phone#:______Reason for Leaving: ______
______Title/Nature of Work: ______
Name/Title of Immediate Supervisor: ______
*Employer: ______Start Date: ______End Date: ______
Address & phone#:______Reason for Leaving: ______
______Title/Nature of Work: ______
Name/Title of Immediate Supervisor: ______
*Employer: ______Start Date: ______End Date: ______
Address & phone#______Reason for Leaving: ______
______Title/Nature of Work: ______
Name/Title of Immediate Supervisor: ______
2. Are you presently employed? Yes No
If yes, may we contact your present employer? Yes No
3. Have you ever been discharged or asked to resign from a job?
Yes No If yes, please explain:______
______
4. Are you subject to any restrictive covenants from prior employment such as agreements to protect confidentiality or proprietary information or agreements not to compete? Yes No
If yes, please explain: ______
______
Professional/Personal References
Provide the following information regarding three (3) people not related to you, who have known you longer than one (1) year.
Name: ______Business: ______
Address: ______Years Acquainted: ______
______Phone Number: ______
Name: ______Business: ______
Address: ______Years Acquainted: ______
______Phone Number: ______
Name: ______Business: ______
Address: ______Years Acquainted: ______
______Phone Number: ______
Last Updated on 10/16/2018 at 4:17 PM
CHDC Employement Application -revision
Community Health & Dental Care, Inc.
11 Robinson St. Suite 100, Pottstown, PA 19464
Telephone: (610) 326-9460 Fax: (610) 326-2432
Educational Information Please complete all appropriate items
*High School or Trade School: ______Yrs completed:______
Location: ______DiplomaG.E.D.____Yes____No
*Business or TechSchool: ______
Location: ______
Major or Course of Study: ______Graduated (date): ______Degree: ______
*College or University:______
Location: ______
Major or Course of Study: ______Graduated (date): ______Degree: ______
*Other Training (explain): ______
Location: ______
Major or Course of Study: ______Graduated (date): ______Degree: ______
Professional Information: (If applicable)
Professional Licensure: ______License No: ______
Effective Date: ______Expiration Date: ______
Registry of Certification: ______Registration No: ______
Effective Date: ______Expiration Date: ______
Out-of-State Licenses: ______License No: ______
Is Pennsylvania Registration Pending? Yes No
Academic Achievements and Activities
Note: Please list academic honors, scholarships, or fellowships; memberships in academic honorary societies; or participation in or offices held in extracurricular activities you consider significant. (You need not disclose membership in professional organizations that may reveal information regarding race, color, creed, sex, religion, national origin, ancestry, age, disability, marital status, veteran status or any other protected status)
______
Last Updated on 10/16/2018 at 4:17 PM
CHDC Employement Application -revision
Community Health & Dental Care, Inc.
11 Robinson St. Suite 100, Pottstown, PA 19464
Telephone: (610) 326-9460 Fax: (610) 326-2432
Do you have any special skills, experience and/or training that would enhance your ability to perform the position applied for? If yes, please explain:______
______
Indicate what languages you speak, read, and/or write.
FluentlyGoodFair
Speak ______
Read ______
Write ______
Please read carefully before signing:
Community Health & Dental Care, Inc. is an equal opportunity employer. Community Health &Dental Care, Inc. does not discriminate in employment on account of race, color, religion, national origin, citizenship status, ancestry, age, sex (including sexual harassment, sexual orientation, marital status, physical or mental disability, military status, or unfavorable discharge from military service.
I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligations for Community Health & Dental Care, Inc. to hire me. If I am hired, I understand that either Community Health & Dental Care, Inc. or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of Community Health & Dental Care, Inc. has the authority to make any assurance to the contrary.
I attest with my signature below that I have given Community Health & Dental Care, Inc. true and complete information on this application. No requested information has been concealed. I authorize Community Health & Dental Care, Inc. to contact references provided for employment reference checks. If any information I have provided is untrue or if I have concealed material information, I understand that this will constitute cause for the denial of employment or immediate dismissal.
Applicant Signature:______Date:______
Last Updated on 10/16/2018 at 4:17 PM
CHDC Employement Application -revision
Community Health & Dental Care, Inc.
11 Robinson St. Suite 100, Pottstown, PA 19464
Telephone: (610) 326-9460 Fax: (610) 326-2432
WRITTEN REQUEST FOR REFERENCE
(Confidential)
I hereby authorize the release to Community Health & Dental Care, Inc. any pertinent information regarding my previous employment.
______
Applicant SignatureDate
Applicant, Do Not Write Below This Line
------
Name: ______SSN: ______
Has applied to us for employment as ______and has stated that s/he was in your employ from ______to ______in the capacity of ______. Please complete the following form and return it to us in the self-addressed envelope at your earliest convenience. Thank you
______
Bridgette McGivern, Chief Executive Officer
Date of Employment ______Date of Termination: ______
Position Held: ______Reason for Termination: ______
Please Check / ExceedsStandards / Meets
Standards / Below
Standards
Quality of Work
Confidentiality
Attendance
Dependability
Cooperation
Initiative
Judgment
Eligible for Rehire? YesNo
If not, why: ______
______
Signature: ______Title: ______
Company Name: ______
Last Updated on 10/16/2018 at 4:17 PM
CHDC Employement Application -revision