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APPLICATION FOR EMPLOYMENT

CIS is an equal opportunity employer. Applicants for all positions are considered without regard to race, color, religion, creed, gender, national origins, age, disability, marital or veteran status, sexual orientation, or any other legally protected status.

Date of Application:

Sun, February 5, 2012

Position(s) Applied For

CIS Clinic Location(s) Applied For:

Last Name

First Name

Middle Name

Address

number

street

city

state

zip code

Telephone Numbers (include area codes):

home

cell

E-Mail Address:

Please check off YES or NO and/or provide additional information:	YES	NO
If you are under 18 years of age, can you provide required proof of your eligibility to work?
Have you ever filed an application with CIS before?
****If you have previously filed an application, give the date
Are you currently employed?
May we contact your present employer?
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration status? (Proof of citizenship or immigration status will be required upon employment.)
On what date are you available to work? Date or timeframe
Are you available to work: Full time Part Time Shift Work Temporary
Are you currently on a "lay-off" satus and subject to recall?
Can you travel if your job requires it?
Have you been convicted of a felony within the last 7 years? (Conviction will not necessarily disqualify an applicant from employment.)
**** If you have been convicted of a felony, please explain:

How did you learn about CIS?

Advertisement Employment Agency Friend Relative
Walk-in Other

EDUCATION	Name and Location of School	Course of Study	Years Completed	Diploma/Degree
Elementary High School
Undergraduate College
Graduate Professional
Other (specify)

Indicate any foreign languages you speak:

Describe any specialized training, apprenticeship, skills, and extracurricular activities:

Describe any job-related training received in the United States military:

OTHER QUALIFICATIONS (Summarize special job-related skills and qualifications acquired from employment or other experience.)

Specialized Skills (check skills/equipment operated)

Transciption	Telephone Switchboard
Computer	Word Perfect
Typewriter	Microsoft Word
Fax	Excel
Calculator	Power Point
Electronic Health Records	Microsoft Project

Other:

State any additional information that you feel may be helpful to CIS in considering your application:

EMPLOYMENT EXPERIENCE

Begin with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status.

Employer (Present or Last)	Dates Employed		Work Performed
	From	To
Address
Telephone Number(s)	Hourly Rate/Salary
	Starting	Final
Job Title			Supervisor
Reason for Leaving

Employer	Dates Employed		Work Performed
	From	To
Address
Telephone Number(s)	Hourly Rate/Salary
	Starting	Final
Job Title			Supervisor
Reason for Leaving

Employer	Dates Employed		Work Performed
	From	To
Address
Telephone Number(s)	Hourly Rate/Salary
	Starting	Final
Job Title			Supervisor
Reason for Leaving

Employer	Dates Employed		Work Performed
	From	To
Address
Telephone Number(s)	Hourly Rate/Salary
	Starting	Final
Job Title			Supervisor
Reason for Leaving

List professional, trade, business, or civic activities and offices held. (You may exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability or other protected status.)

PROFESSIONAL LICENSES
Type of License	License Number	State Issued

REFERENCES	Phone #
Professional or Work Related




Personal

APPLICANT'S STATEMENT
I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. This application for employment shall be considered active for a period of time not to exceed 45 days. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules, regulations, policies and/or procedures of the employer.

Signature of Applicant

Date

If you do not receive a confirmation message sent to your email address after submitting your application, please contact the Human Resources department at (985) 873-5607.

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