I. Personal Information

First Name:

Middle Name:

Last Name:

Address:

City:

State:

Zip Code:

Social Security Number:

Telephone:

Federal law prohibits the employment of unauthorized aliens. All persons hired must submit satisfactory proof of employment authorization and identity (valid driver's license, birth certificate, Green Card, etc.) within three days of being hired. Failure to submit such proof within the required time shall result in immediate employment termination.

Description and title of the position applied for:

Do you have any relatives who are presently (or have formerly been) employed by People's Health Centers?

How were you referred to People's Health Centers ?

Have you ever been convicted of a felony? If yes please explain:

II. Educational History

Jr. High School:

Years Completed:

Degree/Diploma:

High School:

Years Completed:

Degree/Diploma:

College/University:

Years Completed:

Degree/Diploma:

Technical Training:

Years Completed:

Degree/Diploma:

Other Education:

Years Completed:

Degree/Diploma:

III. Employment History

Please include all employment for the last five years.

Company Name
(Current or Most Recent Employer) :

Position Held and Title:

Address (Including: Street, City, State, Zip):

Date Employed (starting and ending):

Manager or Direct Supervisor:

Telephone Number:

Wages and Salary:

Reason for Leaving:

Company Name
(Current or Most Recent Employer) :

Position Held and Title:

Address (Including: Street, City, State, Zip):

Date Employed (starting and ending):

Manager or Direct Supervisor:

Telephone Number:

Wages and Salary:

Reason for Leaving:

Company Name
(Current or Most Recent Employer) :

Position Held and Title:

Address (Including: Street, City, State, Zip):

Date Employed (starting and ending):

Manager or Direct Supervisor:

Telephone Number:

Wages and Salary:

Reason for Leaving:

NOTE: Please list any employers you do not want us to contact and your reason for the exclusion.

Employer's name:

Reason for Exclusion:

Employer's name:

Reason for Exclusion:

IV. References:

Please do not include relatives or former employers

Full Name:

Years Known/Relationship:

Address (Including: Street, City, State, Zip):

Area Code and Telephone Number :

Occupation:

Full Name:

Years Known/Relationship:

Address (Including: Street, City, State, Zip):

Area Code and Telephone Number :

Occupation:

Full Name:

Years Known/Relationship:

Address (Including: Street, City, State, Zip):

Area Code and Telephone Number :

Occupation:

V. Work Availablity

If your application recieves favorable consideration, when will you be available to begin work?

Do you have any objection to working overtime ?

yes or no

Can you work overtime without prior notice ?

yes or no

Can you work on Saturdays ?

yes or no

Can you work on Sundays ?

Can you travel if required by the position ?

yes or no

VI. Salary / Hourly Rate Requirements

If your application receives favorable consideration, what salary/hourly rate would you require ?

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