Patient Specialist (43-70)

First name*

Last name*

Email address*

Location *

Phone number*

Resume*

Do you have a valid driver’s license?*

Are you willing to relocate?*

What’s your citizenship / employment eligibility?*

What’s your highest level of education completed?*

Are you 18 years of age or older?*

What languages do you speak fluently?*

Desired salary*

Earliest start date?*

Can you work weekends?*

Can you work evenings?*

Can you work overtime?*

Have you ever worked for La Clinica de Familia?*

Which of the following are you available to work?*

Have you have ever worked under any other name? If so, please list below.*

Professional References (list at least 3 with name and phone number).*

Please list your last three places of employment in the order of the information listed below (job history must be complete or you will not be considered for employment)

Company Name
Address
Supervisor Name
Supervisor Phone number
Employment Period (start and end date)
Salary
Reason you left*

Please list any specialized or job related skills you feel may be relevant.*

Were you referred by any current employee? If yes, please indicate below.

Are you related to any current employee of La Clinica De Familia? If yes, list the name below.
(If not applicable, please put N/A)*

Are you related to any Board of Directors member, please list the name below.
(If not applicable, please put N/A)*

Do you have a nationally recognized Medical Assistant Certification? (preferred)*

Are you a Certified Community Health Worker (preferred) and have 3 or more years of experience in a health care setting?*

GENERAL DISCLAIMER:

I certify that answers 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 any employment decision.

This application for employment shall be considered active for as long as the position for which the applicant has applied is open.

Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the employee may resign at any time and the Employer may discharge
Employee at any time, with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless an authorized executive of this organization specifically acknowledges such change in writing.

I understand that false or misleading information given in my application or interview(s) may result in my not being hired, or discharged in the event of employment. I understand also, that I am required to abide by all rules and regulations of the employer.

Pleas type you full Legal name to agree to this disclaimer.*

EMPLOYER IMMUNITY FROM LIABILITY FOR REFERENCE ON FORMER EMPLOYEE.

When requested to provide a reference on a former or current employee, an employer acting in good faith is immune from liability for communicating about the former employee's performance. The immunity shall not apply when the reference information supplied was knowingly false or deliberately misleading, was rendered with malicious purpose or violated any civil rights of the former employee. (NM statutes, amended 1978, chapter 50, article12, section 1).

I have read and understand the above statements. I authorize my current and former employer to release information about job performance during my tenure of employment to an agent of La Clinica de Familia.

Please type you full Legal name to agree to this disclaimer.*

CONSENT FOR DRUG SCREENING

I do hereby agree to submit to testing for detection of drugs and alcohol. I give permission for test results to be released to La Clinica de Familia, Inc. I understand that, positive results, refusal to be tested, or any attempt to affect test results or test sample will result in withdrawal of my application for employment, withdrawal of any provisional employment offer I received from La Clinica de Familia or termination of employment, depending on when results are received.

Please type you full Legal name to agree to this disclaimer.*

MOTOR VEHICLE DRIVING RECORD

Your driving record is an important part of your employment application. Employment is contingent upon verification of a good driving record as applicable to the job requirements. You must secure a Motor Vehicle Driving Record as part of the employment process. All information concerning your driving record, and other information set forth in your application, will be verified. False information will result in discharge from employment or termination of the employment application process.

Please type you full Legal name to agree to this disclaimer.*

Human Check*