Application for Employment at RCMS Redwood Coast Medical Services, Inc.An Equal Opportunity Employer Question Title * 1. Tell us about you. Name: last, first middle Mailing Address Physical Address City/Town State/Province ZIP/Postal Code Email Address Phone Number Business Phone Number Question Title * 2. Position applying for: Question Title * 3. Location Gualala Medical Clinic RCMS Dental Point Arena Health Center Question Title * 4. Are you applying for: Regular full-time work? Regular part-time work? Temporary work e.g. summer or holiday work? Question Title * 5. Employment desired: What days and hours are you available for work? If applying for temporary work, during what period of time will you be available? Are you available to work overtime if necessary? If hired, on what date can you start work? Salary desired? Question Title * 6. Personal information: Yes No Have you ever applied or worked for RCMS before? Have you ever applied or worked for RCMS before? Yes Have you ever applied or worked for RCMS before? No Do you have any friends or relatives working for RCMS? (If yes, state name(s) and relationship in the box below.) Do you have any friends or relatives working for RCMS? (If yes, state name(s) and relationship in the box below.) Yes Do you have any friends or relatives working for RCMS? (If yes, state name(s) and relationship in the box below.) No If hired, would you have a reliable means of transportation to and from work? If hired, would you have a reliable means of transportation to and from work? Yes If hired, would you have a reliable means of transportation to and from work? No Are you at least 18 years old? (If under 18, hire is subject to verification that you are of legal minimum age.) Are you at least 18 years old? (If under 18, hire is subject to verification that you are of legal minimum age.) Yes Are you at least 18 years old? (If under 18, hire is subject to verification that you are of legal minimum age.) No If hired, can you present evidence of your U.S. citizenship or proof of your legal right to live and work in this country? If hired, can you present evidence of your U.S. citizenship or proof of your legal right to live and work in this country? Yes If hired, can you present evidence of your U.S. citizenship or proof of your legal right to live and work in this country? No Nature of relationship with current RCMS employee: Question Title * 7. Why are you applying for work at Redwood Coast Medical Services? Question Title * 8. Are you able to perform all other duties of the job for which you are applying? Yes No. If no, describe the functions that cannot be performed: Note: We comply with the ADA and consider reasonable accommodation measure that may be necessary for eligible applicants/employees to perform essential functions. Question Title * 9. Employment: Yes No Are you currently employed? Are you currently employed? Yes Are you currently employed? No If so, may we contact your current employer? If so, may we contact your current employer? Yes If so, may we contact your current employer? No Question Title * 10. Education, Training & Experience Yes. If yes, please put year graduated in the box below. No. If no, please list the highest grade completed in the box below. High School Graduate or General Education (GED) Passed? High School Graduate or General Education (GED) Passed? Yes. If yes, please put year graduated in the box below. High School Graduate or General Education (GED) Passed? No. If no, please list the highest grade completed in the box below. Year graduated or highest grade level completed: Question Title * 11. College/University Name Location Dates Attended Degree Received/Year Major Question Title * 12. Vocational Training /Experience/Certification Name Location Dates Attended Degree Received/Year Question Title * 13. Many of our clients do not speak English. Do you speak, write or understand any foreign languages? Yes No If yes, which language(s)? Question Title * 14. Do you have any other experiences, training qualifications or skills which you feel makes you especially suited for work at Redwood Coast Medical Services? If so, please explain. Question Title * 15. Answer the following questions if you are applying for a professional position. Are you licensed/certified for the job applied for? Name of license/certification: Issuing state: License/Certification number: Has your license/certification ever been revoked or suspended? If yes, state reason(s), date of revocation or suspension, and date of reinstatement. Question Title * 16. Work History 1 Starting and ending dates of employment: Reason for Leaving: Name of Employer: Address: Type of Business: Telephone Number: Your Supervisor’s Name: Your Position and Duties: Question Title * 17. Work History 2 Starting and ending dates of employment: Reason for Leaving: Name of Employer: Address: Type of Business: Telephone Number: Your Supervisor’s Name: Your Position and Duties: Question Title * 18. Work History 3 Starting and ending dates of employment: Reason for Leaving: Name of Employer: Address: Type of Business: Telephone Number: Your Supervisor’s Name: Your Position and Duties: Question Title * 19. Have you obtained any special skills or abilities as the result of services in the military? Yes No If yes, describe: Question Title * 20. List below three persons not related to you who have knowledge of your work performance. Reference 1 Name Occupation Number of years acquainted: Phone Number Question Title * 21. Reference 2 Name Occupation Number of years acquainted: Phone Number Question Title * 22. Reference 3 Name Occupation Number of years acquainted: Phone Number Next
