- First Nations Community HealthSource

Application for Employment

First Nations Community HealthSource, Inc., is an equal opportunity employer (EEO). We consider all applicants for positions without regard to race, color, sex, sexual orientation, gender identity, national origin, citizenship, age, mental or physical disabilities, veteran/reserve/national guard or any other similarly protected status. We also comply with all applicable laws governing employment practices and do not discriminate on the basis on any unlawful criteria.

Today's Date(Required)

Position Applying For:(Required)

Date Available to Start:(Required)

Desired Salary:

Type of Employment Desired:(Required)

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Have you ever worked for First Nations Community HealthSource,(Required)

If you answered yes, please indicate dates of employment:(Required)

The Federal Immigration Reform and Control Act (IRCA) requires us to verify your right to work in the United States. If hired, can you submit verification of your identity and legal right to work in the U.S.?(Required)

If your position requires you to drive, do you have a valid driver’s license?(Required)

Can you, with or without reasonable accommodation, perform the essential functions of the job for which you are applying for?(Required)

The following questions fall under Section 408 of the Indian Child Protection, Family Violence Prevention Act of 1990 Public Law 101-630, Section 231 of the Crime Control Act of 1990 which requires an investigation of the character of each individual who is employed or is considered for employment.

Have you ever been arrested for or charged with a crime involving a child?(Required)

If you answered yes, please explain in detail:(Required)

Have you ever been investigated by a Federal, State or Tribal child protection agency?(Required)

If you answered yes, please explain in detail:(Required)

Have you ever been debarred or suspended from Federal grants or contracts?(Required)

Response confirmation by GAO Excluded Parties List System by Human Resources by (Print Name) Below:

Date

Have you ever been fired from any organization?(Required)

If you answered yes, please explain in detail:

Education History

Please complete the information below which will assist us in evaluating your educational experience.

Education(Required)

Date Completed:(Required)

Name of Institution(Required)

Please include any additional educational information which may assist us in evaluating your skills.

Are you licensed or certified for the position you are applying for?(Required)

Licensure/Certification Name:

License/Certification Number:

State Issued

Has your license or certification ever been revoked or sanctioned?(Required)

If you answered yes, please explain in detail:

Resume(Required)

Drop files here or

Max. file size: 512 MB.

Employment History

Please list all previous employers from the last seven (7) years, starting with your most recent or current employer.

Employer's Name:(Required)

Employer's Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer Phone Number:(Required)

Job Title:(Required)

Responsibilities:(Required)

What are your Hours:

Starting Salary:

Ending Salary:

Supervisor's Name:(Required)

First Last

Supervisor's Phone Number:(Required)

Reason for Leaving:(Required)

May we contact this employer for a reference?(Required)

If you answered No, please explain in detail:(Required)

Were you fired from this employer?(Required)

If you answered yes, please explain in detail:(Required)

Employer's Name:(Required)

Employer's Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer Phone Number:(Required)

Job Title:(Required)

Responsibilities:(Required)

What are your Hours:

Starting Salary:

Ending Salary:

Supervisor's Name:(Required)

First Last

Supervisor's Phone Number:(Required)

Reason for Leaving:(Required)

May we contact this employer for a reference?(Required)

If you answered No, please explain in detail:(Required)

Were you fired from this employer?(Required)

If you answered yes, please explain in detail:(Required)

Employer's Name:(Required)

Employer's Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer Phone Number:(Required)

Job Title:(Required)

Responsibilities:(Required)

What are your Hours:

Starting Salary:

Ending Salary:

Supervisor's Name:(Required)

First Last

Supervisor's Phone Number:(Required)

Reason for Leaving:(Required)

May we contact this employer for a reference?(Required)

If you answered No, please explain in detail:(Required)

Were you fired from this employer?(Required)

If you answered yes, please explain in detail:(Required)

Applicant's Name (Please Print Clearly)(Required)

Application Date:(Required)

Applicant's Signature:

Professional Reference Information

Please list three (3) professional references. Do not include family members.

Reference Name:(Required)

Title:(Required)

Company's Name:(Required)

Email(Required)

Relationship: Cowoker or Supervisor.(Required)

Years Known:(Required)

Reference Name:(Required)

Title:(Required)

Company's Name:(Required)

Email(Required)

Relationship: Cowoker or Supervisor.(Required)

Years Known:(Required)

Reference Name:(Required)

Title:(Required)

Company's Name:(Required)

Email(Required)

Relationship: Cowoker or Supervisor.(Required)

Years Known:(Required)

Reference Name:

Title:

Company's Name:

Relationship: Cowoker or Supervisor.

Years Known:

Reference Name:

Title:

Company's Name:

Relationship: Cowoker or Supervisor.

Years Known:

Applicant's Name (Please Print Clearly):(Required)

Application Date:(Required)

Applicant's Signature:

A Summary of Your Rights Under the Fair Credit Reporting Act

The FCRA gives several different federal agencies authority to enforce the FCRA: