• LanguageSpeak?Read?Write? 
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  • Education

  • School NameSchool AddressAcademic MajorAttended FromAttended To 
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  • TypeState IssuedDate IssuedNo. 
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  • List 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.
  • Experience

  • Give a complete record of all employment and reasons for periods unemployed during the past ten (10) years.

  • Employer #1

  • Employer #2

  • Employer #3

  • Employer #4

  • Employer #5

  • References

  • I 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 #1

  • Reference #2

  • Reference #3

  • Resume

  • Accepted file types: doc, docx, rtf, pdf.
  • EEOC Questionnaire

  • 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.
  • Affidavit

  • I 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.

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    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 Signature
  • Date