Click To Apply Name* First Last Email* Website Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Cell PhonePosition DesiredReferred ByHave you worked for the following companies? Central Coast Community Health Care, Inc. Central Coast VNA & Hospice, Inc. VNA Community Services, Inc. none of the above What days and hours are you available to work?What status would you prefer?* Full Time Part Time Per diem Do you have the legal right to work in the job for which you are applying?* Yes No List languages you speak, read and/or write other than English (optionals)LanguageSpeak?Read?Write? Are you 18 or older?* Yes No EducationEducationSchool NameSchool AddressAcademic MajorAttended FromAttended To Professional Licences, Registrations and/or CertificationsTypeState IssuedDate IssuedNo. Area of Specialization or Major InterestHobbies and InterestsList any hobbies or interests, or membership in any club, organization, society or professional group that has a direct bearing on your qualification for the job which you are seeking. You may omit those which indicate your race, religion, creed, color, national origin, ancestry, sex, sexual orientation, physical or mental impairment, or medical condition.ExperienceList office machines you can useTyping Speed (WPM)Check programs you can use Word Excel Outlook Power Point Please list other equipment you can operateGive a complete record of all employment and reasons for periods unemployed during the past ten (10) years.Employer #1Date Employed From MM slash DD slash YYYY Date Employed To MM slash DD slash YYYY Employer's Name & AddressTelephoneTitleSupervisorSummary of DutiesReason for LeavingMay we contact for reference? Yes NO Employer #2Date Employed From MM slash DD slash YYYY Date Employed To MM slash DD slash YYYY Employer's Name & AddressTelephoneTitleSupervisorSummary of DutiesReason for LeavingMay we contact for reference? Yes NO Employer #3Date Employed From MM slash DD slash YYYY Date Employed To MM slash DD slash YYYY Employer's Name & AddressTelephoneTitleSupervisorSummary of DutiesReason for LeavingMay we contact for reference? Yes NO Employer #4Date Employed From MM slash DD slash YYYY Date Employed To MM slash DD slash YYYY Employer's Name & AddressTelephoneTitleSupervisorSummary of DutiesReason for LeavingMay we contact for reference? Yes NO Employer #5Date Employed From MM slash DD slash YYYY Date Employed To MM slash DD slash YYYY Employer's Name & AddressTelephoneTitleSupervisorSummary of DutiesReason for LeavingMay we contact for reference? Yes NO ReferencesI authorize the company or individual listed below to furnish information regarding my employment history and performance to Central Coast Community Health Care, Inc and Affiliates (CCCHC). I hereby release all individuals and companies listed below from all liability for damage whatsoever that may be incurred as a result of furnishing such information.Reference #1Contact NameContact TitleCompanyAddressPhonePosition TitleStart Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Reason for LeavingReference #2Contact NameContact TitleCompanyAddressPhonePosition TitleStart Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Reason for LeavingReference #3Contact NameContact TitleCompanyAddressPhonePosition TitleStart Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Reason for LeavingResumeUpload your Resume (Word/RTF/PDF)Accepted file types: doc, docx, rtf, pdf, Max. file size: 2 GB. EEOC QuestionnaireName First Last The following statistical information is required for compliance with federal laws assuring equal employment opportunity. Your submission of the information is voluntary. The information you provide on this form will not be used to determine your eligibility or qualification for employment. It will remain in a confidential file separate from your employment application.Please select one EEO Code only:* Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race. White (Not Hispanic or Latino) - A person having origins in any of the peoples of Europe, the Middle East, or North Africa. Black or African American (Not Hispanic or Latino) - A person having origins in any of the black racial groups of Africa. Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) - A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands Asian (Not Hispanic or Latino) - A person having origins in any of the original peoples of the Far East, Southeast Asia or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. American Indian or Alaska Native (Not Hispanic or Latino) - A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment. Two or More Races (Not Hispanic or Latino) - All persons who identify with more than one of the above five races. AffidavitI certify that the answers given by me to the foregoing questions and statements are true and correct without consequential omissions of any kind whatsoever. I agree that my employer shall not be liable in any respect if my employment is terminated because of the falsity of statements, answers or omissions made by me in this application. I authorize employers, companies, schools or persons to give any information regarding my employment, together with any information they may have regarding me whether or not it is in their records. I hereby release said employers, companies, schools or persons from all liability for any damage, both legal and otherwise, for issuing this information. I understand that the agency is committed to providing a safe, efficient and productive workplace. All offers of employment are conditioned upon successful completion of the pre-employment health screening. In addition, if accepted for employment, I hereby agree to abide by the rules and policies of my employer. I affirm that everything is true and correct, and I acknowledge that I can be terminated at anytime if any information I supply is false. I affirm that I have a genuine intent to seek employment and no other purpose in applying for a job with the agency. Further, I understand that any employment is not for a stated period of time and may be terminated with or without cause, at any time, at the option of either myself or my employer with the decision of the president being final.Signature* I Agree (by checking the box, you are agreeing to the above terms as if you signed your name) To be completed by applicant if hired: I affirm that the above terms set forth my complete and final understanding as to that upon which I have agreed to be employed at the Central Coast Community Health Care and its affiliates.Applicant SignatureDateCAPTCHA Δ
