Application - Sokaogon Chippewa Community Health Clinic

New Application

Name

First

Last

Date of Birth

Present Address

Phone Number

Driver's License Number

State Issued

SSN

Tribally Affiliated?

If yes, Where?

Position Desired

Date you can start

Salary Desired

Are you currently employed?

If yes, May we inquire your present employer?

Have you ever worked for this company before?

If yes, where?

High School Education- Name and Location of School, No. of years attended, Completion Date

College- Name and Location of School, No. of years attended, Completion Date, Subject Studied

Trade, Business, or Correspondence School?

Special Skills

Computer Experience

Activities (Civic, Athletic, etc.)

Contact Completion recent

U.S. Military Service?

Rank

Present Membership in National Guard or Reserves?

List your last four employers, starting with most recent first (Dates from-to, employer name address and phone number, salary, position, reason for leaving)

List three persons not related to you, whom you have known for at least one year (name, address, years acquainted, phone number)

Emergency Contact

First

Last

Emergency Contact Phone Number

Emergency Contact Relationship

Signature

I agree

I CERTIFY THAT THE FACTS CONTAIN IN THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND UNDERSTAND THAT, IF EMPLOYED, FALSIFIED STATEMENTS ON THIS APPLICATION SHALL BE GROUNDS FOR DISMISSAL. I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED HEREIN AND THE REFERENCES LISTED ABOVE TO GIVE YOU ANY AND ALL INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT AND ANY PERTINENT INFORMATION THEY MAY HAVE, AND RELEASE ALL PARTIES FROM ALL LIABILITY FOR ANY DAMAGE THAT MAY RESULT FROM FURNISHING THE SAME TO YOU. I UNDERSTAND AND AGREE THAT, IF HIRED, MY EMPLOYMENT IS FOR NO DEFINITE PERIOD AND MAY, REGARDLESS OF THE DATE OF PAYMENT OF MY WAGES AND SALARY, BE TERMINATED AT ANY TIME, WITHOUT PRIOR NOTICE AND WITHOUT CAUSE.