Application | Community Health Center Home Health Care

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

Type of Work Desired

*Position Applied For:

*Position Type:

Full Time Part Time Per Diem Contract

*How did you learn of Community Health Center?

*Date Available:

*Are you presently employed?Yes No

*May we inquire of your present employer?Yes No

Education

	Name and Location of School	Number of Years Completed	Graduated? Yes or No	Subjects Studied
*High School
College
Other (Specify):

Special certifications, training or skills (BLS, computer, languages, etc.):

*Have you ever used any other name at a former place of employment which would be necessary for us to know if we check for references?
Yes No

If yes, give name:

Work Experience

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

*Employer Name:

*Address:

*City:

*State:

*ZIP Code:

*Phone Number:

*Name of Last Supervisor:

*Your Last Job Title:

*Employment Dates: From To

*Reason for Leaving (Be Specific):

*List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

Employer Name:

Address:

City:

State:

ZIP Code:

Phone Number:

Name of Last Supervisor:

Your Last Job Title:

Employment Dates: From To

Reason for Leaving (Be Specific):

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

Employer Name:

Address:

City:

State:

ZIP Code:

Phone Number:

Name of Last Supervisor:

Your Last Job Title:

Employment Dates: From To

Reason for Leaving (Be Specific):

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

Employer Name:

Address:

City:

State:

ZIP Code:

Phone Number:

Name of Last Supervisor:

Your Last Job Title:

Employment Dates: From To

Reason for Leaving (Be Specific):

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

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 agree to and acknowledge the above information. Yes

I confirm the information submitted online is true and accurate.

*Signature:

*Date:

Application For Employment

Counties Served:

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