MISSION STATEMENT Riggs Community Health Center is dedicated to the mission of improving access to quality, cost effective, comprehensive health care with respect and compassion to underserved community members. VALUES R Respect We treat our patients and each other with dignity. I - Integrity and Honesty We are truthful and ethical in our daily actions. G Generosity We provide services to others in need, with kindness and compassion. G - Guaranteed Quality We strive for improvements and desire healthy outcomes in our patient care. S - Stewardship All resources, including staff, supplies, and funding, are managed responsibly. I understand if an offer of employment is extended that I would be responsible to support and represent these values and the mission of Riggs CHC. Signature Printed Name Date
Application for Employment Name: Social Security #: Address: City: State/Zip: Home Phone #: Alternate Phone #: Position Desired: Date you can start: Wage desired: Are you presently employed? No Yes (if yes, where): Do you have any relatives or friends who work for us? No Yes (if yes, who and where they work): Have you ever been employed by us before? No Yes (if yes, please provide dates and supervisor) Are you legally eligible for employment in the United States? No Yes (Proof of identity and legal authority to work in the United States will be required upon employment) How did you hear about us? Advertisement Friend Current Employee Walk in Web Site Other:
EMPLOYMENT HISTORY Include your last three employers (include periods of unemployment, if applicable) and start with the most recent. Name of Present or Last Employer: Address: Your Job Title: Supervisor s Name: Phone No: ( ) From: / / To: / / MM DD YY MM DD YY Duties and Responsibilities: Reason For Leaving: Rate of Pay Name of Next Employer: Address: Your Job Title: Supervisor s Name: Phone No: ( ) From: / / To: / / MM DD YY MM DD YY Duties and Responsibilities: Reason For Leaving: Rate of Pay Name of Next Employer: Address: Your Job Title: Supervisor s Name: Phone No: ( ) From: / / To: / / MM DD YY MM DD YY Duties and Responsibilities: Reason For Leaving: Rate of Pay
Education High School Degree obtained_y / N_ Major/Degree Certification Degree obtained_y / N_ Major/Degree College Degree obtained_y / N_ Major/Degree Skills Please list any other experience, skills, or qualifications which you believe should be considered in evaluating your qualifications for employment. Foreign Languages Please list any foreign language(s) you are able to speak, read, and write fluently: References Please list names and telephone number of three business/work references who are not related to you. If unavailable, list three school/personal references not related to you. Name Company or Organization Telephone # Years Known
I understand and agree that any misrepresentation by me on this application will be sufficient cause for cancellation of this application and/or separation from the Employer s service if I have been employed. I understand that if an offer of employment is extended, it is conditioned upon successful completion of a background investigation and pre-employment drug screen. I give Riggs Community Health Center the right to contact all references and to secure additional information about me, if job related. I hereby release from liability Riggs Community Health Center and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information. Riggs Community Health Center is an Equal Opportunity Employer. Riggs Community Health Center does not discriminate in employment and no questions on this application are used for the purpose of limiting or excusing any applicant s consideration for employment on a basis prohibited by local, state, or federal law. Federal law requires all employers to verify the identity and employment eligibility of all persons hired to work in the United States. Riggs Community Health Center will provide the Social Security Administration (SSA) and, if necessary, the Department of Homeland Security (DHS), with information from each new employee s Form I-9 to confirm work authorization. If the Government cannot confirm that you are authorized to work, this Riggs Community Health Center is required to provide you written instructions and an opportunity to contact SSA and/or DHS before taking adverse action against you, including terminating your employment. Employers may not use E-Verify to pre-screen job applicants or to re-verify current employees and may not limit or influence the choice of documents presented for use on the Form I-9. In order to determine whether Form I-9 documentation is valid, this employer uses E-Verify s photo screening tool to match the photograph appearing on some permanent resident and employment authorization cards with the official U.S. Citizenship and Immigration Services (USCIS) photograph. If you believe that your employer has violated its responsibilities under this program or has discriminated against you during the verification process based upon your national origin or citizenship status, please call the Office of Special Counsel at 1-800-255-7688 (TDD: 1-800-237-2515). This application is current for 90 days. At the conclusion of this time if I have not heard from Riggs Community Health Center and still wish to be considered for employment, it will be necessary to fill out a new application. I understand that just as I am free to resign at any time, the Riggs Community Health Center reserves the right to terminate my employment at any time, with or without cause and with or without prior notice. I understand that no representative of Riggs Community Health Center has the authority to make any assurances to the contrary. Signature of Applicant Date Rev 11/16
Rev 02/15 AFFIRMATIVE ACTION INFORMATION FORM We are an affirmative action government contractor. In compliance with government regulations we are required to track the number of our applicants by gender, race / ethnicity, and position for which applied. We invite you to indicate your gender and race / ethnicity below. This information will be kept separately from your application and will be used only in accordance with federal and state regulations. YOU ARE NOT REQUIRED TO PROVIDE THIS INFORMATION. Your application for employment will be considered in the same manner whether or not you fill out this form. GENDER Male Female RACE / ETHNIC GROUP White (Not of Hispanic origin) All persons having origins in any of the original peoples of Europe, North Africa, or Middle East. Black (Not of Hispanic origin) All persons having origins in any of the black racial groups of Africa Hispanic All persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race. Asian or Pacific Islander All persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands. This area includes, for example, China, India, Japan, Korea, the Philippine Islands, and Samoa. American Indian or Alaskan Native All persons having origins in any of the original peoples of North America, and who maintain cultural identification through tribal affiliation or community recognition. Other (Please Specify) Name: Position applied for: Date of application: Referred by: How did you learn about the position?