Employment Application - Mendocino Coast Clinics

Email *

First Name *

Last Name *

Date *

Mobile Number *

Home Number

Current Address *

City *

US States *

Languages Spoken *

Have you ever been terminated from employment or asked to resign by an employer? *

If yes, please provide company names and details?:

Are you eligible to work in the US? *

Can you work any shift? *

Are you able to perform the essential functions of the job for which you are applying, with or without a reasonable accommodation? *

Can you work overtime if necessary *

Position Desired *

Date you can start *

Rate/Salary desired *

Are you currently employed?

If so, may we contact your present employer for a reference?

Referral Source:

Have you ever worked for this company before?

Do you know anyone who works for this company?

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Education

High School or GED
College or University
Trade, Business, or Correspondence School

High School or GED:

College or University:

Trade, Business or Correspondence School:

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Employment History:

1. Employer Name

Start Date of Employment

End Date of Employment

Phone Number

Job Title

Address

Supervisor & Title

Summarize the nature of work and job responsibilities:

Reason for leaving:

2. Employer Name

Start Date of Employment

End Date of Employment

Phone Number

Job Title

Address

Supervisor & Title

Summarize the nature of work and job responsibilities:

Reason for leaving:

3. Employer Name

Start Date of Employment

End Date of Employment

Phone Number

Job Title

Address

Supervisor & Title

Summarize the nature of work and job responsibilities:

Reason for leaving:

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Do you have any skills, experience and/or training that would enhance your ability to perform the position applied for?

Computer Skills (please describe):

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References: Give the names of three persons not related to you, whom you have known at least three (3) years.

1. Reference:

2. Reference:

3. Reference:

Please read carefully before submitting: *

Mendocino Coast Clinics is an equal opportunity employer. Mendocino Coast Clinics does not discriminate in employment on account of race, color, religion, national origin, citizen status, ancestry, age, sex (including sexual harassment), sexual orientation, marital status, physical or mental disability, military status or unfavorable discharge from military service. I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for Mendocino Coast Clinics to hire me. If I am hired, I understand that either Mendocino Coast Clinics or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of Mendocino Coast Clinics has the authority to make any assurance to contrary. I attest with my signature below that I have given to Mendocino Coast Clinics to contact references provided for employment reference checks. If any information I have provided is untrue, or if I have concealed material information, I understand that this will constitute for the denial of employment or immediate dismissal.

Date *

Signature: *