Online Application Form

Applicant Information

Please Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Applicant Availability

If Under 18, please list age:
Position Applied for: Salary Desired:

Days/Hours Available to Work:

Employment Desired:

How many hours can you work weekly?

When are you available for work?

Criminal History

If yes, explain number of conviction(s), nature of offense(s), how recent such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation.

Drivers License Information

Driver's License Number: State of issue: Please Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Expiration Date:

Licensure Information and Certification

For positions requiring a professional license, please provide the following information regarding your license. Please list any additional training or certification including, but not limited to, CPR, ACLS, TNCC, BLS, ATLS, PALS, NRP, etc.

Professional License Number and Expiration Other Certification(s) and Expiration Date(s)

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Education

Type of School... High School College Business or Trade School Professional School Check if Completed:

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Type of School... High School College Business or Trade School Professional School Check if Completed:

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Type of School... High School College Business or Trade School Professional School Check if Completed:

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Type of School... High School College Business or Trade School Professional School Check if Completed:

Work Experience

Please list your work experience beginning with your most recent job held. If you were self-employed, give firm name.

Please Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Date Started Date Ended Pay/Salary Started Pay/Salary Ended Reason for leaving (be specific) List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

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Please Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Date Started Date Ended Pay/Salary Started Pay/Salary Ended Reason for leaving (be specific) List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

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Please Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Date Started Date Ended Pay/Salary Started Pay/Salary Ended Reason for leaving (be specific) List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

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Please Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Date Started Date Ended Pay/Salary Started Pay/Salary Ended Reason for leaving (be specific) List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

Additional Comments

An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the space below to summarize any additional information necessary to describe your full qualifications for the specific position for which you are applying.

Additional Document

If you have additional work experience or cover letter you would like to include, please attach it here. (Accepted file types: .pdf, .doc, .docx, .rtf, and .odt up to 4MB in size)

Personal References

Please include two personal references.

First Reference:

Second Reference:

Application Form Waiver

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Please Read Carefully

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In exchange for the consideration of my job application by Coal Country Community Health Center (hereinafter called "the Company"), I agree that:

Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or anyother position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of Coal Country Community Health Center, or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the President/CEO of the Company. If employed, I understand that the Company may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits.

I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give the Company permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release the Company from any liability as a result of such contract.

I also understand that (1) the Company may have a drug and alcohol policy that provides for pre-employment testing as well as testing after employment; (2) consent to and compliance with such policy may be a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy.

I further understand that continued employment may be based on the successful passing of job related physical examinations. I further understand that my employment with the Company shall be introductory for a period of ninety (90) days, and further that at any time during the introductory period or thereafter, my employment relation with the Company is terminable at will for any reason by either party.

By checking this box I certify that I have read, fully understand, and agree to the Application Form Waiver above.

Submit Application

By entering my full name I recognize the above information I have entered to be true and accurate to the best of my knowledge.

This Company is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with this Company depends solely on your qualifications.