LA CLINICA DE FAMILIA, INC.
Application For Employment
WE ARE AN EQUAL OPPORTUNITY EMPLOYER
We consider applicants for all positions without regard to race, color, creed, gender, national origin, age, disability, martial or veteran status, sexual orientation, or any other legally protected status.

 
Position(s) applied for
Type of Employment Desired Full time    Part time    Temporary
How did you learn about us? Advertisement
Friend
Walk-In
Employment Agency
Relative
Other 
First Name
Middle Name
Last Name
Address
City
State
Zip Code
Phone Number
Best time to contact      
Social Security Number
Have you ever worked under another name?   No    Yes    If yes, please list:
If you are under 18 years of age, can you provide proof of your eligibility to work?    No    Yes  
Have you ever filed an application with us before?    No    Yes  
Are you currently employed?    No    Yes  
If yes, why do you wish to change position?
Are you currently on "lay-off" status and subject to recall?    No    Yes  
May we contact your present employer ?    No    Yes  
(Current/previous employers must be contacted for final candidates before hiring decisions can be made.)
Have you ever been employed with us before ?    No    Yes  
If yes, give dates and positions held.
On what date would you be available to work?      
Are you available to work: Full time
Part time
Shift work
Temporary
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration status?  
No    Yes  
(Proof of citizenship or immigration status will be required upon employment.)
Can you travel if the job requires it?   No    Yes  
Have you been convicted of a felony within the last 7 years?   No    Yes  
If yes, please explain.
(Criminal convictions are NOT an absolute bar to employment, but will only be considered with respect to the specific requirements of the job for which you are applying.)
Education
School Type
Name and Location of School
Course of Study
Years Completed
Did You Graduate?
Graduate Professional
No    Yes
College
 No    Yes 
Business Trade/Other Technical
No    Yes
High School
No    Yes 
 
Indicate any foreign languages you can speak, read and/or write
 
Fluent
Good
Fair
Speak
Read
Write
 
Describe any specialize training, apprenticeships, skills and extra-curricular activities
 
Professional Information (if applicable)
Years Completed: License Number:
Effective Date:      
Expiration Date:      
 
Other Qualifications (Summarize special job related skills and qualifications acquired from employment or other experience you feel may be helpful to us in considering your application.)
Employment Experience
Please give accurate and complete full-time and part-time employment information. Start with your present or last job. Include any job-related military service assignments and volunteer activities. Exclude organizations which indicate race, color, religion, gender, national origin, disabilities, or other protected status.
Company Name: Telephone:
Address: Employed (Month/Year)
City, State, Zip: From: To:
Name of Supervisor: Job Title:
Describe work performed: Hourly rate or Salary:
Start: Final:
Reason for Leaving:
Company Name: Telephone:
Address: Employed (Month/Year)
City, State, Zip: From: To:
Name of Supervisor: Job Title:
Describe work performed: Hourly rate or Salary:
Start: Final:
Reason for Leaving:
Company Name: Telephone:
Address: Employed (Month/Year)
City, State, Zip: From: To:
Name of Supervisor: Job Title:
Describe work performed: Hourly rate or Salary:
Start: Final:
Reason for Leaving:
Company Name: Telephone:
Address: Employed (Month/Year)
City, State, Zip: From: To:
Name of Supervisor: Job Title:
Describe work performed: Hourly rate or Salary:
Start: Final:
Reason for Leaving:
Company Name: Telephone:
Address: Employed (Month/Year)
City, State, Zip: From: To:
Name of Supervisor: Job Title:
Describe work performed: Hourly rate or Salary:
Start: Final:
Reason for Leaving:
List professional, trade, business, or civic activities and office held and any job-related training recieved. (You may exclude memberships, which would reveal gender, race, religion, national origin, age, ancestry, disability or other protected status.)
 
Specialized Skills (Check skills or equipment operated.)
Fax
Calculator
Typewriter
PBX System		 Terminal
Computer
MS Excel
MS Word		 Production/Mobile Machinery (list):
Other (list):
 
Do not answer this question unless you have been informed about the requirements of the job for which you are applying.
Are you capable of performing in a reasonable manner with/without reasonable accommodation, the essential activities involved in the job or occupation for which you have applied? A description of the activities involved in such a job or occupation is attached. Yes No
 
Professional References
Phone:
Phone:
Phone:
 
Notes
By clicking the submit button I agree to the following...

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.
 
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.

  Security image
* Security Code:

Please type in the letters you see in the above image. If you are having trouble with the current image please refresh this page.

 
La Clinica de Familia - Administrative Office - 385 Calle de Alegra - Las Cruces, NM 88005 - (575) 526-1105
©2007-2010 LA CLINICA DE FAMILIA INC. All rights reserved.