Online Application
If hired, can you furnish proof of citizenship or legal entry into the U.S.?
Do you give consent to perform a criminal background check?
Have you ever been convicted of a crime? .If "YES" please explain (Conviction of a crime is not an automatic bar to employment. The Clinic will consider the nature of the offense, the date, and the relationship between the offense and the position applied for.)
Are you an active service member?
Have you ever served in the U.S. Armed Forces?
List in Training received while inservice:
Do you have any physical conditions or a handicap, which may limit your ability to perform the job applied for? If yes, what can be done to accommodate your limitation?
Would you be willing to take a Physical Examination and Drug Test at the Clinic's expense if offered the job?
Do you have any friends or relatives currently working for us or serving on our Board of Directors or Task Force?
Are you currently employed?

EDUCATION

Do you have job related licenses or certifications?
List any experiences; skills, training, or qualifications, which you feel, would be especially helpful in the job you are applying for:
List Clerical Skills, if any:
Specialized Programs (Accounting, Database, File Management):

EMPLOYMENT HISTORY

(List chronologically, starting with the most recent employer)

Reason for Leaving:
Position held/Description of your duties:


Reason for Leaving:
Position held/Description of your duties:


Reason for Leaving:
Position held/Description of your duties:


Reason for Leaving:
Position held/Description of your duties:

References: Excluding Relatives

Name and Occupation
Address
Telephone Number

Applicant's Authorization and Certification:

Please Read CAREFULLY before signing: I certify that all the information provided by me in connection with my application, whether on this document or not, is true and complete, and I understand that any misstatement, falsification, or omission of information shall be grounds for refusal to hire, or, if hired, termination. I authorize any of the persons, organizations, and educational institutions referenced in this application to give officials of Central Care Integrated Health Services any and all information concerning my previous employment, education, or any other information they might have, personal or otherwise, with regard to any of the subjects covered by this application, and I release all such parties from all liabilities from any damages which may result from furnishing such information to Central Care Integrated Health Services.

I UNDERSTAND THAT ALL PERSONS OFFERED EMPLOYMENT BY THE CENTRAL CARE INTEGRATED HEALTH SERVICES MUST SUCCESSFULLY PASS A DRUG TEST AS A CONDITION OF EMPLOYMENT.

I UNDERSTAND THAT NOTHING IN THIS APPLICATION SHALL BE CONSTRUED AS A CONTRACT OR AN OFFER OF EMPLOYMENT. IF HIRED, I UNDERSTAND THAT I WILL BE EMPLOYED AT-WILL, AND CENTRAL CARE INTEGRATED HEALTH SERVICES HAS THE RIGHT TO TERMINATE MY EMPLOYMENT AT ANY TIME AND I MAY TERMINATE MY EMPLOYMET AS WELL.