Application For Employment

We consider applicants for all positions without regard to race, color, religion, creed, sex, national origin, age, disability, marital or veteran status, sexual orientation, genetic predisposition or carrier status, or any other legally protected status.

* Required Field
Personal Information

Yes No    

   

Yes No

Yes No
(A "yes" answer will not preclude you from being hired.)


Yes No

Yes No

Type of Work Desired

   

Yes No    

Yes No    

Education
  Name and Location of School Number of Years Completed Graduated? Yes or No Subjects Studied
*High School
College



Yes  No

Work Experience

Please list your work experience beginning with your most recent job held. If you were self-employed, give firm name.

 From To

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 From To

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 From To

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References

From the list above list three persons, not related to you, with whom you have worked. Include Director, Manager, Supervisor, etc.

*Name *Position *Company
*Address *Telephone
*Name *Position *Company
*Address *Telephone
*Name *Position *Company
*Address *Telephone

I UNDERSTAND THAT I MAY BE REQUIRED TO WORK ANY DAY(S) OF THE WEEK INCLUDING EVENINGS, WEEKENDS, HOLIDAYS AND "ON CALL" ROTATION AS ASSIGNED BY MY SUPERVISOR (EFFORT WILL BE MADE TO ACCOMMODATE SINCERELY HELD RELIGIOUS OBSERVANCES).

I hereby affirm the accuracy of the information contained in this application and authorize Community Health Center to investigate such information. I understand and agree that misrepresentation or omission of any facts called for is cause for dismissal. Employment offers are contingent upon successfully meeting New York State Department of Health, health and immunization requirements, and Federal Office of the Inspector General and the Office of the Medicaid Inspector General corporate compliance programs. This application may require a Department of Health (DOH) – FBI Criminal History Record Check, a New York State Central Register of Child Abuse and Maltreatment Database check. I also understand the agency has the ability to engage in employee drug testing. Except as prohibited by law, the agency has the right to discharge at will.

I certify that I am not an ineligible person who has been excluded, suspended, debarred or deemed ineligible to participate in a federally funded healthcare program.

   

I confirm the information submitted online is true and accurate.

Counties Served:

Fulton, Montgomery, Herkimer, Schoharie, Saratoga, Hamilton, and Warren Counties