APPLICATION FOR EMPLOYMENT

Primaris

200 N. Keene St.
Columbia, MO65201

An Affirmative Action/EqualOpportunity Employer

POSITION APPLIED FOR: You must fill out all sections of this application completely and honestly. This information will be used to determine your eligibility for this position. (NOTE: A separate application must be completed for each position for which you are applying.) PLEASE PRINT OR TYPE.

Position Applied for: / Date Available to Start Work: / Salary Expected: / Date of Application:
Type of Position Requested
Full-Time Part-Time Regular Part-Time (list days/hrs available to work):

PERSONAL INFORMATION

Name (Last, First, Middle Initial)
, / Have you been employed under other names? Yes No
List Name(s):
Address (Street, City, State, Zip Code)
Home Phone Number
() / Work Phone Number
() / May we contact you at work?
Yes No
Have you applied for work here before? Yes No
List dates and positions: / Have you ever been employed here before? Yes No
List dates and positions:
Are you related to anyone currently employed by Primaris? Yes No
List name(s) and department(s):
Are you less than 18 years old? Yes No
If yes, state age:
(Proof of age may be required after job offer.) / Have you ever been convicted of a felony? Yes No
If yes, please state date, place, and nature of conviction:
(A conviction does not constitute an automatic bar to employment.)
How did you find out about this job opening?
Web page (Identify) Primaris (Identify)
Newspaper (Identify) Other (Please explain):
Are you legally authorized to work in the U.S.? Yes No
(Employment will be contingent on providing proof of citizenship or work authorization.)

EDUCATION, TRAINING, SKILLS

Please list all education beginning with most recent. Indicate a diploma or degree, if completed, including GED if obtained.

Name & Location of School / Grade Point Average / Curriculum/Major / Degree/Diploma/Certificate
College/University
College/University
Other Education
High School/GED
OFFICE/COMPUTER SKILLS
Word Processing Presentation Software CRT
Database Desktop Publishing Ten key by touch Other (list)
Spreadsheet Typing wpm Phone Systems
SKILLS/CERTIFICATIONS/PROGRAMMING LANGUAGES: List technical or specialized skills/credentials relevant to this job, including driver's license (list type of license and name of state where issued), certifications, professional licenses, and knowledge of any computer programming languages or specialized software or hardware.
CIVIC/PROFESSIONAL/TRADE ASSOCIATION MEMBERSHIPS/ACTIVITIES:
REFERENCES (Please include name, position/title, address, and telephone number of THREE references):

EMPLOYMENT HISTORY: List last three employers including military, self-employment, and part-time jobs starting with the most current position held. May also show job-related volunteer experience.

1. Present or Last Employer’s Name/Address
Supervisor's Name/Title/Phone: / May we contact for references
Yes No
Positions Held:
Dates Employed (month/year) / Position 1: / Full-time
Part-time, hrs/wk / Salary
Start: $ /Month/Week/Year / Final: $ /Month/Week/Year
From: / To:
Dates Employed (month/year) / Position 2: / Full-time
Part-time, hrs/wk / Salary
Start: $ /Month/Week/Year / Final: $ /Month/Week/Year
Dates Employed (month/year) / Position 3: / Full-time
Part-time, hrs/wk / Salary
Start: $ /Month/Week/Year / Final: $ /Month/Week/Year
Reason for leaving:
Duties:
2. Employer Name/Address
Supervisor's Name/Title/Phone: / May we contact for references
Yes No
Positions Held:
Dates Employed (month/year) / Position 1: / Full-time
Part-time, hrs/wk / Salary
Start: $ /Month/Week/Year / Final: $ /Month/Week/Year
From: / To:
Dates Employed (month/year) / Position 2: / Full-time
Part-time, hrs/wk / Salary
Start: $ /Month/Week/Year / Final: $ /Month/Week/Year
Dates Employed (month/year) / Position 3: / Full-time
Part-time, hrs/wk / Salary
Start: $ /Month/Week/Year / Final: $ /Month/Week/Year
Reason for leaving:
Duties:
3. Employer Name/Address
Supervisor's Name/Title/Phone: / May we contact for references
Yes No
Positions Held:
Dates Employed (month/year) / Position 1: / Full-time
Part-time, hrs/wk / Salary
Start: $ /Month/Week/Year / Final: $ /Month/Week/Year
From: / To:
Dates Employed (month/year) / Position 2: / Full-time
Part-time, hrs/wk / Salary
Start: $ /Month/Week/Year / Final: $ /Month/Week/Year
Dates Employed (month/year) / Position 3: / Full-time
Part-time, hrs/wk / Salary
Start: $ /Month/Week/Year / Final: $ /Month/Week/Year
Reason for leaving:
Duties:

PLEASE BE SURE TO READ THE FOLLOWING STATEMENTS CAREFULLY AND SIGN THIS APPLICATION:I certify that all information I have provided on this application is true and complete to the best of my knowledge. I understand that omitting requested information or giving false information on my application, in my interview(s), or in the process of my pre-employment evaluation may result in rejection of my application or termination if I am hired. I authorize investigation of all statements in this application as may be necessary in arriving at an employment decision. I understand that this application does not represent an offer of, or contract for, employment. I understand that employment with the Missouri Patient Care Review Foundation is "at will," and that no guarantee of job exists. If employed, I, or the Missouri Patient Care Review Foundation, can terminate the employment relationship at any time, with or without prior notice, for any reason not prohibited by statute.

APPLICANT’S SIGNATURE:______DATE:______


Voluntary Affirmative Action Information

Primaris

200 N. Keene St.
Columbia, MO65201

An Affirmative Action/EqualOpportunity Employer

(Completion of Information Below is Voluntary)

We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, the presence of a non-job-related medical condition or handicap, or any other legally protected status.

Position(s) applied for: / Date of Application:
Referral Source:
Web page (Identify)
Newspaper (Identify)
Primaris (Identify)
Government employment agency
Non-Government employment agency / Walk-in
School
Friend
Relative
Other (Please explain):
Applicant’s Name (Last, First, Middle Initial)
,
Address (Street, City, State, Zip Code) / Home Phone Number
()
As required, we comply with government regulations including Affirmative Action obligations where they apply. In an effort to comply with requirements regarding government record keeping, reporting and other legal obligations, we ask that you complete this applicant data survey. Your cooperation is appreciated. Please be advised that your survey is not a part of your official application for employment. It is considered confidential information that will not be used in any hiring decision.
Are you Hispanic or Latino? – A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. / Yes
No (if no, please check appropriate category below)
Race/Ethnic Group (check one):
BLACK or AFRICAN AMERICAN (Not Hispanic or Latino) - A person having origins in any of the Black racial groups of Africa. Terms such as "Haitian" or "Negro" can be used in addition to "Black or African American."
WHITE (Not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.
AMERICAN INDIAN or ALASKAN NATIVE (Not Hispanic or Latino) - A person having origins in any of the original peoples of North America and South America (including Central America), and who maintains tribal affiliation or community attachment.
ASIAN (Not Hispanic or Latino) - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
NATIVE HAWAIIAN or OTHER PACIFIC ISLANDER (Not Hispanic or Latino) - A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other PacificIslands
Two or More Races (Not Hispanic or Latino) – All persons who identify with more than one of the above five races.
Gender:
Male Female / Check if any of the following are applicable:
Vietnam Era Veteran Disabled Veteran Other Protected Veteran Handicapped Individual

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