APPLICATION FOR EMPLOYMENT

Qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, veteran status or disability. We will make reasonable accommodation for the known disabilities of otherwise qualified applicants and employees, provided that it does not cause undue hardship.
Date of Application:
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Position(s) Applied For:
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How did you learn about us?
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  • Advertisement
  • Friend
  • Walk-In
  • Employment Agency
  • Relative
  • Other
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First Name:
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Middle Name:
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Last Name:
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Address:
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City:
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State:
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  • Alabama
  • Alaska
  • Arizona
  • Arkansas
  • California
  • Colorado
  • Connecticut
  • Delaware
  • District of Columbia
  • Florida
  • Georgia
  • Hawaii
  • Idaho
  • Illinois
  • Indiana
  • Iowa
  • Kansas
  • Kentucky
  • Louisiana
  • Maine
  • Montana
  • Nebraska
  • Nevada
  • New Hampshire
  • New Jersey
  • New Mexico
  • New York
  • North Carolina
  • North Dakota
  • Ohio
  • Oklahoma
  • Oregon
  • Maryland
  • Massachusetts
  • Michigan
  • Minnesota
  • Mississippi
  • Missouri
  • Pennsylvania
  • Rhode Island
  • South Carolina
  • South Dakota
  • Tennessee
  • Texas
  • Utah
  • Vermont
  • Virginia
  • Washington
  • West Virginia
  • Wisconsin
  • Wyoming
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Home Phone Number:
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Cell Phone Number:
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Zipcode:
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Are you at least 18 years old?
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If hired, can you provide proof that you are eligible to work in the United States?
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Have you ever been employed by Memphis Health Center, Inc. before?
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If yes, give date and location.
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EMPLOYMENT EXPERIENCE

List each job held. Start with your Present or Last job. Include military service assignments and volunteer activities. (Exclude groups which indicate race, color, religion, sex, national origin, or disability).
Employer Name:
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Employer Telephone Number:
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Employer Address:
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Job Title:
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Supervisor Name:
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Reason for Leaving:
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Work Performed:
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Dates Of Employment

Start Date:
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End Date:
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Hourly Rate / Salary

Starting Rate:
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Final Rate:
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EMPLOYMENT EXPERIENCE 2

List each job held. Start with your Present or Last job. Include military service assignments and volunteer activities. (Exclude groups which indicate race, color, religion, sex, national origin, or disability).
Employer Name:
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Employer Telephone Number:
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Employer Address:
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Job Title:
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Supervisor Name:
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Reason for Leaving:
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Work Performed:
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Dates Of Employment

Start Date:
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End Date:
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Hourly Rate / Salary

Starting Rate:
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Final Rate:
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EMPLOYMENT EXPERIENCE 3

List each job held. Start with your Present or Last job. Include military service assignments and volunteer activities. (Exclude groups which indicate race, color, religion, sex, national origin, or disability).
Employer Name:
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Employer Telephone Number:
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Employer Address:
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Job Title:
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Supervisor Name:
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Reason for Leaving:
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Work Performed:
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Dates Of Employment

Start Date:
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End Date:
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Hourly Rate / Salary

Starting Rate:
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Final Rate:
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Are you currently employed?
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If yes, may we contact your present employer for a reference?
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Summarize special skills and qualifications acquired from employment or experience.
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On what date would you be available for work?
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What type of Shift are you available to work?
  • - select a option -
  • Full Time
  • Part Time
  • Sift Work
  • Temporary
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Do any of your friends or relatives work here?
(Relatives means kinship of blood or marriage)
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If yes, list names.
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Do any of your family members serve on the Board of Directors of the Memphis Health Center?
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If yes, list names
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Have you ever been convicted of a felony or misdemeanor?
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If yes, please explain:
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Are you a veteran of the U.S. Military Service?
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If yes, what was your Branch of U.S. Military Service & how many years served?
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Give name, addresses, and phone numbers of three references not related to you and who are not previous employers.
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EDUCATION

High School
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High School Name:
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High School Address:
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High School Course of Study:
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Check Last Year Completed?
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  • Freshman (9th Grade)
  • Sophomore (10th Grade)
  • Junior (11th Grade)
  • Senior (12th Grade)
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Did you graduate?
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Diploma or Degree?
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College
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College Name:
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College Address:
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College Course of Study:
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Select Last Year of College Completed:
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  • Freshman
  • Sophomore
  • Junior
  • Senior
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Did You Graduate College?
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College Diploma or Degree?
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Other
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Other School Name:
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Other School Address:
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Other School Course of Study:
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Select Other School Last Year Completed
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  • 1
  • 2
  • 3
  • 4
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Did you graduate?
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Diploma or Degree?
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State any additional educational information you feel may be helpful to us in considering your application:
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APPLICANT'S STATEMENT

I certify that all statements contained in this application, or made in conjunction with it, are true and correct, and any misrepresentation or omission of fact called for is grounds for disqualification from employment or will result in dismissal, should I be employed, whenever the correct information becomes known to Memphis Health Center, Inc. I understand that this application for employment does not in any way constitute an offer of employment or a contract of employment. Employment with the Center is not by contract express or implied. Also should I be employed I understand that my employment is for no definite duration but is on an "at-will" basis and no representative of the Center has the authority to make any assurances to the contrary except the Chief Executive Officer in writing. I give the Center, or its designated agent, the right to check all references and the right to secure additional information about me including a background check and credit report. I also authorize all my current and former employers, school officials, instructors or any other person, whether or not named in this application, to give the Center, or its designated agent, any information they may have about me, whether or not such information is in their written records. I release the Center and its representative from any liability for any damages resulting from its requesting reference information regarding me. I release those companies, agencies and individuals supplying reference information from any liability for any damages resulting from the giving of such information. I agree that all papers, keys, identification cards, credit cards, tools, equipment or other property furnished by the Center, or which were prepared or made at any time while employed by the Center shall be the property of the Center and upon its request or the termination of my employment, I will promptly surrender any such property to the Center. I understand that if employed, all of the Center's policies and procedures, including its policy manuals and documents (in whole or in part) do not constitute a contract of employment. I agree to read and familiarize myself with all written policies and procedures, which are subject to modification by the Center without notice. I understand that this application is current for thirty (30) days following the date entered below. At the end of the thirty (30) days, if I have not heard from the Center, and still wish to be considered for employment, it will be necessary to fill out a new application. I certify that I have read the job description which describes the essential functions of the job for which I have applied and that I can perform all of the essential functions of the job with or without reasonable accommodation and that I satisfy all of the requirements for the job. The above is subject to modification only by written agreement signed by the applicant and an authorized representative of the Center. My signature below certifies that I have read and understood the above paragraphs.
Signature:
Type Name to sign
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Date:
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MEMPHIS HEALTH CENTER IS AN EQUAL OPPORTUNITY EMPLOYER