EMPLOYMENT APPLICATION

Name*
First Last
Date
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
How did you hear about us?
Are you 18 years of age or older?*
- Yes
- No
Are you either a U.S. citizen or authorized to work in the U.S.?*
- Yes
- No
Have you ever worked or attended school under another name? If so, under what name?*
Vacancy Desired
Position Applying For*
Start date available
MM slash DD slash YYYY
Rate of Pay Desired
Rate of pay by
- Hourly
- Monthly
- Annually
Do you prefer
- Full-TIme
- Part-Time
If part-time, hours per week desired
Hours you are available to work per week
Days of week you are available to work
Are you able to work (select all that apply)
- Saturday
- Holidays
- Evenings (until 8:00pm)
- Overtime
Have you previously worked for HOPE Clinic?
- Yes
- No
Dates of employment with HOPE Clinic
Reason(s) for leaving
Education
High School
Graduated?
- Yes
- No
Course of Study
Technical School
Graduated?
- Yes
- No
Course of study
College/University
Graduated
- Yes
- No
Course of Study
Other education, training, certifications or special skills acquired
Skills
Typing Speed (WPM)
Are you experienced in using a personal computer?
- Yes
- No
Are you experienced with Microsoft Word?
- Yes
- No
Level
- Beginner
- Intermediate
- Advanced
List other computer programs/software you are experienced in using
What languages do you speak and understand?*
Work Experience
Please list previous work experience with most recent first.
Employer 1*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
From*
To*
Position Held*
Reason for leaving*
Supervisor's Name & Title*
Supervisor's Phone*
May we contact?*
- Yes
- No
Description of duties*
Starting compensation*
Final Compensation*
Employer 2
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
From
To
Position Held
Reason for leaving
Supervisor's Name & Title
May we contact?
- Yes
- No
Description of duties
Starting compensation
Final Compensation
Authorization and Acknowledgements
Please read the following statements carefully and indicate your understanding and acceptance by responding in the affirmative in the space provided. I certify that all the information in this application is true and correct, and I further understand that any misstatement or omission of information may be grounds for disqualification or immediate dismissal. I authorize all persons listed on my application to give HOPE Clinic any and all information regarding my previous employment and education and any other pertinent information they may have, personal or otherwise, and release all parties, such persons, and HOPE Clinic from liability for any damage that may result from furnishing same to HOPE Clinic. I certify that all the information contained in this application (and any accompanying information that I may submit) is true and correct, and further understand that any misstatement or omission of information is grounds for rejection of employment, or if employed, termination from HOPE Clinic. In addition, I authorize HOPE Clinic to obtain copies of any information pertaining to any criminal history maintained by any law enforcement agency and to use said information for the purpose of evaluation of my application for employment. I understand that any falsification of this record will be sufficient cause for disqualification. I understand that this application becomes the property of HOPE Clinic which reserves the right to accept or reject it. I understand that personal or other information obtained from my references becomes a part of this record, is to be regarded as confidential and shall not be revealed to me. If employed by HOPE Clinic, I understand that I must conform to the rules, regulations and policies of HOPE Clinic. If I am employed in HOPE Clinic without a contract (at will), I understand that my employment can be terminated, with or without cause or notice, at any time, at the discretion of either HOPE Clinic or myself. I further understand that no representative of HOPE Clinic, other than the Chief Executive Officer (CEO) of HOPE Clinic, has any authority to enter into any agreement, oral or written, for employment for any specified period of time or to make any assurance or promise of continued employment. This application becomes a public record and is subject to disclosure, except as otherwise noted. By checking the box below you are providing an electronic signature confirming your understanding of, and agreement with, all terms and conditions stated above.
I, the applicant, confirm, understand and agree to all of the terms above.*
- I agree
*Not all applicants will be contacted, only qualified/finalists will be contacted.
Resume Upload*
Max. file size: 256 MB.
Cover Letter Upload
Max. file size: 256 MB.

FTCA

As a Federally Qualified Health Center (FQHC), HOPE receives HHS funding and Federal Public Health Service (PHS) deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals.

HOPE Clinic is a Health Center Program grantee under 42 U.S.C. 254b, and a deemed Public Health Service employee under 42 U.S.C. 233(g)-(n).