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

Please carefully read all the questions. If you do not understand a question, please ask for an explanation. Answer all questions fully, honestly and completely. Do not leave any questions blank. If the question does not apply to you, print "n/a" to indicate that the question is "not applicable." Failure to follow these instructions will be considered by Ambucare Clinic in making employment decisions. Any false, misleading or incomplete answers may result in immediate disqualification of consideration for employment or termination of subsequent employment.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.


Position(s) Applied For: Today's Date
* Last Name: * First Name: Middle
How did you hear about us? If other selected, please answer below.
* Present Address  
* City: * * Zip:
* Telephone Number: * Email Address:
If you are under 18 years of age, can you provide
required proof of your eligibility to work?
 Yes  No
Have you ever filed an application with us before?  Yes  No
If yes, please give dates and position:
Have you ever been employed with us before?  Yes  No
If yes, please give dates and position:
Are you currently employed?  Yes  No
May we contact your present employer?  Yes  No
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?
Proof of citizenship or immigration status
will be required upon employment.
 Yes  No
On what date would you be available for work?
Are you able to work? Full Time Part Time Shift Work Temporary
Are you currently on "lay-off" status and subject to recall? Yes No
Can you travel if job requires it? Yes No
Have you ever been arrested or convicted of a
crime that has not been expunged by a
court within the last seven years?
 Yes  No
If yes, please give the date(s) and details: