“Through the teamwork of our partners, staff and board members, The Providence Community Health Centers continues to ensure that everyone in Providence has access to quality medical and dental care.”
~Merrill Thomas, CEO, The Providence Community Health Centers, Inc.

Job Opportunities - Application

Application For Employment

Applicants are considered for all positions without regard to race, color, religion, sex, sexual orientation, national origin, age, marital or veteran status or physical or mental disability. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Department.

Position(s) applied for:
Requistion # (Req.)
If applying for a specific position, please include the Requistion number located next to the title of the job description.
Date of application:
Referral Souce:

Advertisement
Friend
Relative
Walk-in
Employment Agency
Other
Name of Source:

First Name:
Middle Name:
Last Name:
Address:
City:
State:
Zip Code:
Telephone:
Cell Phone:
Email Address:
Have you ever been employed by PCHC before? yes no
If yes, when?
Are you employed now? yes no
If yes, may we contact your employer? yes no
Are you legally eligible for employment in this country? yes no
Do you have a relative on the Board of Directors? yes no
Date available for work?
Type of employment desired:

Full-Time
Part-Time
Temporary

Are you available to work 2 days a week from 12pm - 8pm and 3 days from 9am - 5pm? yes no
If applying for a float position, do you have reliable transportation? yes no

Employment History
Please provide the following information for your current and past employment including military and volunteer activities, starting with the most recent. Be sure to list ALL prior jobs. PCHC requires 7-10 years of employment verification, where applicable. Attach another sheet, if necessary.
From:
To:
Employer:
Telephone:
Job Title:
Address:
Immediate Supervisor:
Supervisor's Title:
Summarize the nature of work performed and job responsibilities:
Reason for leaving:
Hourly rate/salaryStart:
Final:

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From:
To:
Employer:
Telephone:
Job Title:
Address:
Immediate Supervisor:
Supervisor's Title:
Summarize the nature of work performed and job responsibilities:
Reason for leaving:
Hourly rate/salaryStart:
Final:

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From:
To:
Employer:
Telephone:
Job Title:
Address:
Immediate Supervisor:
Supervisor's Title:
Summarize the nature of work performed and job responsibilities:
Reason for leaving:
Hourly rate/salaryStart:
Final:

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From:
To:
Employer:
Telephone:
Job Title:
Address:
Immediate Supervisor:
Supervisor's Title:
Summarize the nature of work performed and job responsibilities:
Reason for leaving:
Hourly rate/salaryStart:
Final:

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From:
To:
Employer:
Telephone:
Job Title:
Address:
Immediate Supervisor:
Supervisor's Title:
Summarize the nature of work performed and job responsibilities:
Reason for leaving:
Hourly rate/salaryStart:
Final:
  
Skills and Qualifications
Summarize any training, skills, licenses, and/or certificates that may qualify you to perform job-related functions in the position for which you are applying. (Exclude information which would reveal sex, race, religion, national origin, age, disability or other protected status).

  
Educational Background
Name of High School:
Years Completed:
Did you Graduate from High School? yes no
Course of Study in High School:
  
Name of College:
Years Completed:
Did you Graduate from College? yes no
What was your major in College?
What degree did you receive?
Course of Study in College:
  
Other:
Years Completed:
Did you Graduate? yes no
Course of Study:
  
Language Abilities
List the languages ou speak, read and write; then rate your proficiency by circling one (little, fairly, or well).
Language Spoken:

Speak:
Little Fairly Well

Read:
Little Fairly Well

Write:
Little Fairly Well

  
Language Spoken:

Speak:
Little Fairly Well

Read:
Little Fairly Well

Write:
Little Fairly Well

  
Language Spoken:

Speak:
Little Fairly Well

Read:
Little Fairly Well

Write:
Little Fairly Well

  
Have you participated in any Medical Interpretation Training? yes no
If yes, for how long?
  
References (Include two work supervisors)
Name:
Company:
Position:
Shift:
Telephone:
Years Known:

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Name:
Company:
Position:
Shift:
Telephone:
Years Known:

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Name:
Company:
Position:
Shift:
Telephone:
Years Known:
  
Additional Information (List special accomplishments, awards, etc.)
  

I UNDERSTAND THAT IF I AM EMPLOYED, ANY MISREPRESENTATION MADE BY ME ON THIS APPLICATION MAY RESULT IN CANCELLATION OF THIS APPLICATION OR IMMEDIATE DISCHARGE FROM PCHC’S SERVICE, WHENEVER IT IS DISCOVERED.

I GIVE PCHC THE RIGHT TO CONTACT AND OBTAIN INFORMATION FROM ALL REFERENCES, EMPLOYERS, EDUCATIONAL INSTITUTIONS AND TO OTHERWISE VERIFY THE ACCURACY OF THE INFORMATION CONTAINED IN THIS APPLICATION. I HEREBY RELEASE FROM LIABILITY PCHC AND ITS REPRESENTATIVES FOR SEEKING, GATHERING AND USING SUCH INFORMATION AND ALL OTHER PERSONS, CORPORATIONS OR ORGANIZATIONS FOR FURNISHING SUCH INFORMATION.

PCHC DOES NOT UNLAWFULLY DISCRIMINATE IN EMPLOYMENT AND NO QUESTION ON THIS APPLICATION IS USED FOR THE PURPOSE OF LIMITING OR EXCUSING ANY APPLICANT FROM CONSIDERATION FOR EMPLOYMENT ON A BASIS PROHIBITED BY LOCAL, STATE OR FEDERAL LAW.

THIS APPLICATION IS RETAINED FOR 90 DAYS. AT THE CONCLUSION OF THIS TIME, IF YOU HAVE NOT HEARD FROM PCHC AND STILL WISH TO BE CONSIDERED FOR EMPLOYMENT, IT WILL BE NECESSARY TO FILL OUT A NEW APPLICATION.

IF I AM HIRED, I UNDERSTAND THAT I AM FREE TO RESIGN AT ANY TIME, WITH OR WITHOUT CAUSE, AND PCHC RESERVES THE SAME RIGHT TO TERMINATE MY EMPLOYMENT AT ANY TIME, WITH OR WITHOUT CAUSE AND WITHOUT PRIOR NOTICE. THIS APPLICATION DOES NOT CONSTITUTE AN AGREEMENT OR CONTRACT FOR EMPLOYMENT FOR ANY SPECIFIC PERIOD OR DEFINITE DURATION. I UNDERSTAND THAT NO REPRESENTATIVE OF PCHC, OTHER THAN AN AUTHORIZED OFFICER, HAS THE AUTHORITY TO MAKE ANY ASSURANCES TO THE CONTRARY. I FURTHER UNDERSTAND THAT ANY SUCH ASSURANCES MUST BE IN WRITING AND SIGNED BY AN AUTHORIZED OFFICER.

I UNDERSTAND IT IS PCHC’S POLICY NOT TO REFUSE TO HIRE A QUALIFIED INDIVIDUAL WITH A DISABILITY BECAUSE OF THAT PERSON’S NEED FOR A REASONABLE ACCOMMODATION AS REQUIRED BY THE ADA.

I ALSO UNDERSTAND THAT IF I AM HIRED, I WILL BE REQUIRED TO PROVIDE PROOF OF IDENTITY AND LEGAL WORK AUTHORIZATION. I represent and warrant that I have read and fully understand the foregoing and seek employment under these conditions.

By checking this box, you agree that the transmission and submission of this form serves as legal authorization that the information being submitted is true and correct to the best of your knowledge. You also agree that your electronic signature is as legally binding as your hand-written signature.

Signature of Applicant:

Date:   

 
 
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