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SOUTH COVE COMMUNITY HEALTH CENTER, INC. EMPLOYMENT APPLICATION South Cove Community Health Center, Inc. ( South Cove ) offers equal employment opportunity to all applicants for employment and all employees
SOUTH COVE COMMUNITY HEALTH CENTER, INC. EMPLOYMENT APPLICATION South Cove Community Health Center, Inc. ( South Cove ) offers equal employment opportunity to all applicants for employment and all employees regardless of sex, age, race, color, religion, national origin, ancestry, veteran status, sexual orientation, disability, or any other status protected by applicable law. An applicant who does not meet the minimum qualifications of the position(s) for which the applicant applies will not be considered for employment. Please indicate the facility in which you are applying for employment: South Street, Boston Washington Street, Boston Quincy Thank you for applying to SCCHC. Please complete each section of this application. (please print clearly) PERSONAL DATA Name Social Security No. Last Name First Name Initial Present Telephone ( Street Number and Name Message Telephone ( City State Zip Code ) ) Best time to contact you A.M. P.M. Are you legally authorized to work in the U.S.? Yes No If you are hired, will you be able to submit proof of your identity and eligibility for employment in the United States? Yes No (Identity and employment eligibility of all new hires will be verified as required by Immigration Reform and Control Acts of 1986) Please list any relatives employed by South Cove: Name Position Relationship to you EDUCATION AND TRAINING Name of School & Number of years Course or Major Diploma/Degree -1- Professional and Technical Applicants only: Professional License Number Type of License or Certification Place of Issue Expiration Date Please list any professional organizations of which you are a member If you are licensed or certified, has your license or certification ever been suspended or revoked or are you currently involved in any proceeding that could affect your license or certification? Yes No If you answer yes to the above please give dates, location and disposition of the case POSITION(S) DESIRED Position(s) applied for Salary desired Schedule preferred: Full-time Part-time Days and hours preferred If you are made an offer of employment, when are you available to begin work? How did you become aware of the position(s) for which you are applying? (Please give individual or source) LANGUAGE PROFICIENCY (CHOOSE ALL THAT APPLY) LANGUAGE FLUENTLY SOME NONE FLUENTLY SOME NONE English Cantonese Taiwanese Mandarin Vietnamese Spanish Other EMPLOYMENT HISTORY Have you ever been employed by South Cove, its affiliates, or any related entities? Yes No If you answered yes, please identify the dates and location: Have you ever been discharged from a job? Yes No If yes, please provide details: -2- Are you presently employed? Yes No List all of your places of employment beginning with the most recent. You may include work performed on a volunteer basis. Please account for any time period between positions when you were not employed. South Cove may contact any of these persons or entities to obtain an employment reference. From To Name and of Employer Job Title & Duties From To Name and of Employer Job Title & Duties From To Name and of Employer Job Title & Duties From To Name and of Employer Job Title & Duties From To Name and of Employer Job Title & Duties PERSONAL AND PROFESSIONAL REFERENCES (DO NOT LIST RELATIVES) -3- Name, Occupation and Relationship to you Telephone Number Please use the space below to provide any additional information relating to your qualifications for the position(s) (i.e., specialty training such as OB/GYN, use of special equipment, knowledge of computer software, etc.) CRIMINAL RECORD INFORMATION An applicant for employment with a sealed record on file with the commissioner of probation may answer no record with respect to any inquiry herein relative to prior arrests, criminal court appearances or convictions. In addition, an applicant for employment may answer no record with respect to any inquiry relative to prior arrests, court appearances and adjudications in all cases of delinquency or as a child in need of services which did not result in a complaint transferred to the superior court for criminal prosecution. Have you ever been convicted of a felony? Yes No Within the past five (5) years, have you been convicted of, or completed a period of incarceration due to a conviction of, a misdemeanor (other than drunkenness, simple assault, speeding, minor traffic violations, affray, or disturbance of the peace)? Yes No If you answered Yes to either or both question(s), please identify the crime(s), date(s), court(s), and disposition(s): Federal/State Program Authorization SCCHC is a federal/state contractor and must ensure that prospective employees are not excluded, debarred, or otherwise ineligible to work within any Federal/State health program. 1. To the best of your knowledge, are you eligible to work within all Federal/State programs? Yes No 2. Have you been proposed as ineligible to work within any Federal/State programs? Yes No -4- CERTIFICATION (PLEASE READ CAREFULLY BEFORE SIGNING) I hereby certify and affirm that the information provided in conjunction with the application process, including the information provided on this Application for Employment and any resume submitted, is true and complete, and that I have withheld nothing that would, if disclosed, affect this Application unfavorably. I hereby authorize South Cove to investigate all information pertinent to my Application for Employment in order to determine my qualifications for employment, which may include contacting former and/or current employers or any other person or entity listed on this Application. I hereby authorize all persons and entities having information relevant to my Application to provide that information to South Cove and I hereby agree to hold harmless South Cove and all those providing information to South Cove from any liability arising out of or as a result of the request for, provision of, or use of such information. I understand that any offer of employment may be rescinded or my employment terminated if my references are inadequate or unacceptable to South Cove or if I violate any of the provisions of this Certification. I also understand that I am required to complete forms, separate from this application, that authorize the procurement of Criminal Offender Record Information ( CORI ) checks from the Massachusetts Criminal History System Board, and generally that authorize procurement of consumer reports be background checking agencies. If I am offered and accept employment with South Cove, I agree to wear and use all protective clothing and devices required by South Cove and to comply with all safety policies and procedures. I understand that any job offer, or if hired my continuing employment, is contingent upon my being able, with or without reasonable accommodation, to successfully perform the essential functions of the position for which I am hired. I also understand that if I am employed in a safety sensitive position that, as a condition of continued employment with South Cove, I may be required to submit to a drug/alcohol test to the extent permitted by law. I understand that the authorizations, described herein apply during the application process and throughout the course of my relationship with South Cove. I understand that completion of this Application does not assure me of a position with South Cove. I also understand that neither this Application nor any other document constitutes a contract of employment for a specific term and that any employment relationship that may be established will be at will. As such, any employment relationship I may have with South Cove may be terminated at any time, for any reason or no reason, by me or South Cove. I understand that no representative of South Cove, other than the Executive Director, has the authority to enter into any agreement for employment with me contrary to the foregoing. I understand that any omission, misrepresentation, or falsification in conjunction with this application process may be grounds for denial of employment or, if hired, immediate termination of employment. I further understand that if I am hired by South Cove, I must abide by all rules and policies of South Cove, which, other than that at-will employment policy, may be changed without notice at the discretion of South Cove. Applicant s signature Date It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability. -5-
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