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FCHC Employment Application

APPLICATION FOR EMPLOYMENT

Family Care Health Centers (FCHC) considers all applicants for employment without regard to race, color, religion, sex national origin, age, disability, sexual orientation, gender identity or veteran status, in accordance with federal law. In addition, FCHC complies with applicable state and local laws prohibiting discrimination in employment in every jurisdiction in which it maintains facilities.

Name(Required)

First Middle Last

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Phone Number(Required)

Email address(Required)

Are You legally entitled to work in the United States?(Required)

YES

Are you over the age of 18?(Required)

YES

Are you related to a current employee or Board Member of Family Care Health Centers?(Required)

YES

If So, Whom?

Have you ever been employed by Family Care Health Centers?(Required)

YES

If Yes, when?

Position for which you are applying?(Required)

Salary Expected per HOUR/WEEK/MONTH/YEAR(Required)

Other positions for which you would like to be considered(Required)

Which of the following would you be able to work?(Required)

Weekdays Only

Evenings

Saturdays

Is there anything that would prevent you from performing, in a reasonable and safe manner, the essential functions of the position for which you have applied?(Required)

YES

If yes, please explain

If your application is considered favorably, on what date can you start work?(Required)

Have you ever been convicted of a crime?(Required)

YES

If yes, state the nature of the offense, when, where and disposition.

*A conviction record will not necessarily be a bar to employment. This information will be used for job-related purposes and only to the extent permitted by law.

Employment History

(please list most recent position first)

Employer One

Employer Name

Address

Street Address City State / Province / Region ZIP / Postal Code

Employer Phone Number

Job Title

Supervisor Name

First Last

Start Date

End Date

Starting Salary

Ending Salary

Reason for Leaving

May we contact them

YES

Employer Two

Employer Name

Address

Street Address City State / Province / Region ZIP / Postal Code

Employer Phone Number

Job title

Supervisors Name

First Last

Start Date

End Date

Starting Salary

Ending Salary

Reason For Leaving

May we Contact Them?

YES

Employer Three

Employer Name

Address

Street Address City State / Province / Region ZIP / Postal Code

Employer Phone Number

Job Title

Supervisor Name

First Last

Start Date

End Date

Starting Salary

Ending Salary

Reason For Leaving

May We Contact Them?

YES

Have you ever served in the U.S Armed Forces?

YES

If yes, List Duties in the service, Including special training that is relevant to the position for which you have applied:

Education

High School Name

High School Address

Street Address City State / Province / Region ZIP / Postal Code

Number of Years Attended

Degree

College Name

College Address

Street Address City State / Province / Region ZIP / Postal Code

Number of Years Attended

Degree

Major

Graduate School Name

Graduate School Address

Street Address City State ZIP Code

Number of Years Attended

Degree

Major

Other Schooling

Courses now studying

Pre - Employment Statement

(Please Read and Sign the statement below)

I understand and agree that:

1. The information that I have provided on this application is true and complete to the best of my knowledge. Any misreprenstation or omission of any fact in my application, resume, or any other materials, or during any interviews, can be justification for refusal to consider my application further, or, if employed, termination from Family Care Health Centers' employ.

2. Any offer of employment I may receive from Family Care Health Centers is contingent upon my successful completion of the company's total pre-employment screening process, including the company's receiving references that it considers satisfactory, and my satisfactory completion of my physical examination that the Center may require.

3. I understand that as a condition of employment I may be required to undergo and successfully pass a screening for alcohol, and/or drugs. I also understand and agree that, if employed, I may be required to submit to alcohol and drug screening as set forth in Family Care Health Centers' Substance Abuse Policy.

4. In Processing my application for employment, Family Care Health Centers may conduct a background screening.

5. I authorize and request that all of my present and former employers furnish information about my employment record, including a statement of the reason for the termination of my employment, work performance, abilities, and other qualities pertinent to my qualifications for employment, and I hereby release requested information.

6. In consideration of my employment, I agree to comply with the policies, rules, regulations, and procedures of the company. I understand that FCHC requires certain vaccinations, Including Covid and Influenza, and that I must be vaccinated absent a medical or religious exemption. Other vaccines may be required. I understand that my employment and compensation can be terminated with or without cause of notice, at any time, at the option of either the Center or myself. I further understand that no manager or representative of the Center, other than the Chief Executive Officer or his/her representative, has any authority to enter into any agreement with me for employment for any specified period of time or to make any agreement different from or contrary to the foregoing.

Signature

First Last

Date