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
If other selected, please answer below.

Personal Information
Last Name
First Name
Middle
Present Address
City
State
Zip
Telephone Number
Email Address

If you are under 18 years of age, can you provide required proof of your eligibility to work?
Have you ever filed an application with us before?
Have you ever been employed with us before?
If yes, please give dates and position:
Are you currently employed?
May we contact your present employer?
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.
Are you currently on "lay-off" status and subject to recall?
Can you travel if job requires it?
Have you ever been arrested or convicted of a crime that has not been expunged by a court within the last seven years?
If yes, please give the date(s) and details:
Are you able to work?
On what date would you be available for work?

Education, Training and Skill set
Name(s) of Educational Institution(s)
Diploma(s)/Degree(s)
Describe Course of Study or Major
Describe Specialized Training, Experience, Skills and Extra-Curricular Activities
Indicate any foreign languages you can speak, read and write and your level of fluency.
Describe any specialized training/apprenticeship skills and extra-curricular activities.
Describe any job-related training received in the United States Military.

EMPLOYMENT HISTORY
Start with your present or last job. Include any job-related military service service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender national origin, disabilities or other protected status.
Name of Present or Last Employer Name
Phone
Address
Name/Title of Supervisor
May we contact this employer?
Job Title
Start and End Dates of Employment
Reason for Leaving
Please summarize this positions professional responsibilities and job duties

Name of Present or Last Employer Name
Phone
Address
Name/Title of Supervisor
May we contact this employer?
Job Title
Start and End Dates of Employment
Reason for Leaving
Please summarize this positions professional responsibilities and job duties

Name of Present or Last Employer Name
Phone
Address
Name/Title of Supervisor
May we contact this employer?
Job Title
Start and End Dates of Employment
Reason for Leaving
Please summarize this positions professional responsibilities and job duties

If applicable, please explain fully any gap in your employment history:

Additional Information
Summarize your special job related skills and qualifications acquired from employment or other experience.
Equipment/Software Skills - Summarize any special job related equipment or software skills.
List professional, trade, business or civic activities and offices held. You may exclude organizations which indicate race, color, religion, gender national origin, disabilities or other protected status.
Professional, trade, business or civic activities and offices held
State additional information you fell may be helpful in us considering your application. Note to applicants: DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING.
Additional Information

Are you capable of performing in a reasonable manner, with or without a reasonable accommodation, the activities involved in the job or occupation for which you have applied? A description of the activities involved have been provided on our website.

PERSONAL REFERENCES Please list persons who can comment on your work habits, responsibility, character and conduct. Do not include relatives.
Reference Name
Phone
Email
Reference Name
Phone
Email
Reference Name
Phone
Email

APPLICANT CERTIFICATION AUTHORIZATION AND RELEASE I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. This application for employment shall be considered active fir 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. I hereby understand and acknowledge that unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an exclusive executive of this organization. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer. I HAVE CAREFULLY READ THIS ENTIRE APPLICATION FOR EMPLOYMENT AND FULLY UNDERSTAND ALL OF ITS CONTENTS AND INSTRUCTIONS.
Date Signed
Applicant Signature