It is the policy of Agape Community Health Center, Inc. (Agape) is to provide equal opportunity with regard to all terms and conditions of employment. Agape complies with federal and state laws prohibiting discrimination on the basis of race, color, religion, creed, national origin, disability, veteran status, age or any other protected characteristic.
Name:
Last First Middle
Address:
Street City State Zip Code
How long at this address?
Telephone# ( ) Other Phone # ( ) ____
Former address: ______
Position(s) applied for Date of application / __/ ______
Referral Source (How did you hear about us?) ______
If you are under 18 and it is required, can you furnish a work permit? Yes No If no, please explain
Have you submitted an application here before? Yes No
If yes, give date(s) and position(s) ______
Have you ever been employed here before? Yes No
If yes, give date(s) and position(s) ___
List any friends or relatives currently employed by this Company: ______
Are you legally eligible for employment in this country? Yes No Date available for work... / /
What is your desired salary range or hourly rate of pay? $
Type of employment desired: Full-Time Part-Time Educational Co-Op
Seasonal Temporary
Will you travel if job requires it? Yes No What % of the time?
If they have been explained to you, are you able to meet the attendance requirements for this position?
N/A Yes No
Will you work overtime if required? Yes No
If no, please explain
Driver’s license number (required if driving may be required in the job for which you are applying):
State
Have you ever been convicted of or pled no contest to a crime; ever been a defendant in any civil action for intentional tort; had an adjudication withheld for a criminal offense; entered a pre-trial intervention program; or been placed on court ordered probation? Yes No. If yes, state the nature of the offense(s), date(s), city and state and disposition below. A conviction or plea record is not an automatic bar to employment and the nature, date, disposition of an offense, and other factors deemed relevant by the employer will be considered as they relate to the job for which you are applying.
Employment HistoryStarting with your most recent employer, provide the following information. Account for all periods of time including military service, part-time and/or volunteer activities and any periods of unemployment. If self- employed, give firm name and supply business references. Attach a separate sheet if necessary.
PLEASE GIVE MONTH AND YEAR.
Current/Most Recent Employer: Name / JOB TITLE
ADDRESS / DATE OF EMPLOYMENT: FROM: / TO
CITY/STATE/ZIP / RATE OF PAY: START: / FINAL:
SUPERVISOR / TELEPHONE / REASON FOR LEAVING
May we contact for reference? / Yes / No / Later
NAME OF EMPLOYER / JOB TITLE
ADDRESS / DATE OF EMPLOYMENT: FROM: / TO
CITY/STATE/ZIP / RATE OF PAY: START: / FINAL:
SUPERVISOR / TELEPHONE / REASON FOR LEAVING
May we contact for reference? / Yes / No / Later
NAME OF EMPLOYER / JOB TITLE
ADDRESS / DATE OF EMPLOYMENT: FROM: / TO
CITY/STATE/ZIP / RATE OF PAY: START: / FINAL:
SUPERVISOR / TELEPHONE / REASON FOR LEAVING
May we contact for reference? / Yes / No / Later
May we contact for reference? / Yes / No / Later
IN CASE OF EMERGENCY, NOTIFY:
Name / Phone Number / Relationship
Address / City/State
Skills and Qualifications
Summarize any special training, skills, licenses and/or certificates that may assist you in the position for which you are applying.
Starting with your most recent school attended, provide the following information.
School Name / (City and State) / Years Completed / Diploma/Degree/ CertificateReferences
List Name and telephone number of three business/work references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references that are not related to you.
Name / Title / Relationshipto You / Telephone / # years Known
Please sign and date the Applicant’s Statement on the next page.
APPLICANT'S STATEMENT
I understand that misrepresentation, omissions of facts, or incomplete information requested may result in my not being considered for employment.
I certify all statements given herein are true and complete and, if employed, I understand that false and misleading statements given in my application or interview(s) may result in dismissal, regardless of the time they are discovered.
I authorize investigation of all statements contained in this application and any attachments for employment including contact of my previous employers, verification of education, a criminal background check, driver’s license history and other information as may be necessary in arriving at an employment decision. I hereby release Agape Community Health Center, Inc. (Agape) and all persons and organizations from any and all claims and liability of any kind arising from such investigation or the supplying of information as part of such process.
I understand that I am required to abide by all policies and procedures of Agape, and that my offer of employment may be contingent upon successfully passing a drug screen and other screens. After a conditional job offer, I may be required to complete a post-job offer medical history questionnaire and/or undergo a medical examination. I understand that if I am employed I will be subject to a 90 calendar day introductory period.
I understand that my employment with Agape is for no specific term and may be terminated by me with or without notice or cause at any time and that Agape has a similar right. I further understand that no oral promise, Agape policy, custom, business practice or other procedure constitutes an employment contract or modification of the at-will employment relationship between me and Agape.
Signature of Applicant:
Date: / /