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Applicant Information
Required fields are marked with an asterisk (*).
Today's Date*
Date Format: MM slash DD slash YYYY
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Date Available*
Date Format: MM slash DD slash YYYY
Desired Salary*
Position Applied For*
Job Grouping*
Preferred Location*
Are you legally authorized/eligible to work in the United States?*
- Yes
- No
Have you ever worked for this company?*
- Yes
- No
If yes, when?*
Have you ever been convicted of a felony?*
- Yes
- No
If yes, explain*
Resume
Cover Letter

Education
Required fields are marked with an asterisk (*).
High School*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Did you graduate?*
- Yes
- No
Diploma*
College
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Did you graduate?
- Yes
- No
Degree
Other
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Did you graduate?
- Yes
- No
Degree

References
Please list three professional references. Required fields are marked with an asterisk (*).
Reference 1*
First Last
Relationship*
Company*
Phone*
Email
Reference 2*
First Last
Relationship*
Company*
Phone*
Email
Reference 3*
First Last
Relationship*
Company*
Phone*
Email

Previous Employment
Please provide 10 years of employment history and/or any gaps in employment. Additional references may be requested if unable to contact previous supervisors. Required fields are marked with an asterisk (*).
Company*
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Supervisor*
First Last
Job Title*
Starting Salary*
Ending Salary*
Responsibilities*
From*
Date Format: MM slash DD slash YYYY
To*
Date Format: MM slash DD slash YYYY
Reason for Leaving*
May we contact your previous supervisor for a reference?*
- Yes
- No
If no, why?*
Company
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Supervisor
First Last
Job Title
Starting Salary
Ending Salary
Responsibilities
From
Date Format: MM slash DD slash YYYY
To
Date Format: MM slash DD slash YYYY
Reason for Leaving
May we contact your previous supervisor for a reference?
- Yes
- No
If no, why?
Company
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Supervisor
First Last
Job Title
Starting Salary
Ending Salary
Responsibilities
From
Date Format: MM slash DD slash YYYY
To
Date Format: MM slash DD slash YYYY
Reason for Leaving
May we contact your previous supervisor for a reference?
- Yes
- No
If no, why?

Military Service
Branch
From
Date Format: MM slash DD slash YYYY
To
Date Format: MM slash DD slash YYYY
Rank at Discharge
Type of Discharge
If other than honorable, explain

Professional Licenses and Certifications
Required fields are marked with an asterisk (*).
Are you licensed/certified for the job you have applied for, if applicable?*
- Yes
- No
- N/A
Name of license/certification*
Licensing/certification number*
Issuing State/Agency*
Expiration Date*
Date Format: MM slash DD slash YYYY
Has your license/certification ever been revoked or suspended?*
- Yes
- No
If yes, state the reason(s), date of revocation or suspension and date of reinstatement.*

Attestation, Disclaimer, and Signature
Community Health Center of Southeast Kansas, Inc. (CHC/SEK) is an equal opportunity employer. In employment, CHC/SEK does not discriminate because of race, color, religion, sex, gender, sexual orientation, national origin, ancestry, disability, marital status, or age. Required fields are marked with an asterisk (*).
Consent*
I agree to the terms below
Attestation: I certify and attest that my answer are true and complete to the best of my knowledge, without consequential omissions of any kind whatsoever. If this application leads to my employment at CHC/SEK, I understand that false or misleading information in my application or interview may result in the termination of my employment at CHC/SEK.

I understand that the Immigration Reform and Control Act of 1986 requires all employers to verify IDENTITY and EMPLOYMENT AUTHORIZATION for all employees, and that CHC/SEK may take all necessary steps to verify my IDENTIFY and EMPLOYMENT AUTHORIZATION.

I hereby authorize any educational institution and my former employers to provide any information they may have regarding me.

I understand that a conditional offer of employment may be based on results of an investigative background check and a later health assess/examination.

If employed by CHC/SEK, I hereby agree to be paid in accordance with the Fair Labor Standards Act, and that the Fair Labor Standards Act provides that an employee (myself) may be paid every two (2) weeks.

If employed by CHC/SEK, I hereby agree to abide by the policies, protocols, and rules of CHC/SEK. That CHC/SEK and the employee (myself) have a right to freely enter into the employment relationship and sever the relationship at any time, for any reason. Accordingly, I understand that any employment, by CHC/SEK, is not for a stated period of time and may be terminated, with or without cause, at any time, at the option of either CHC/SEK or the employee (myself).

In the event that CHC/SEK should be or become subject to the conditions of the Drug-Free Workplace Act of 1988, I agree to abide by such established policies as related thereto.

Disclaimer: I agree that CHC/SEK shall not be liable in any respect if my employment is terminated because of false statements, answers, or omissions made by me in this application or interview.

I disclaim and release educational institutions and their employees, former employers and their employees, and CHC/SEK and its employees from any and all liability, whatsoever, for providing, obtaining, exchanging, and/or discussing information and documentation associated with my educational background and work experience.

Signature: By signing my name below, I agree with and to the contents, terms, and conditions of the Attestation and the Disclaimer immediately above. In the event I had any questions about the Attestation and the Disclaimer, I understand that by signing my name immediately below that I am freely and openly stating that I no longer have any questions regarding the Attestation and the Disclaimer, that I had any questions answered to my liking, and that I agree with and to the contents, terms, and conditions of the Attestation and the Disclaimer.
Signature*
Name
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Applicant Information

Education

References

Previous Employment

Military Service

Professional Licenses and Certifications

Attestation, Disclaimer, and Signature