We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, or any other legally protected status. FHCP is an EOE/AA/Drug-Free Workplace Employer.

INCOMPLETE APPLICATIONS WILL NOT BE
CONSIDERED FOR EMPLOYMENT.

Position Applied For:

Social Security Number:--
(Required)

Applicant Name:
Last: First:   Middle:

Address Information:
Number: Street:
City: State: ZIP:

Telephone Number: *Please Include your Area Code

Are you over 16 years of age? Yes   No

Wages or Salary Expected? $ Per Hr.    Per Week

On what date would you be available for work?
Are you available to work Full Time  Part-Time  Shift Work  Temporary  Pool
Will you work overtime if asked? Yes  No
Have you filed an application here before? Yes  No 
(If Yes, Give Date) 
Have you ever been employed here before? Yes  No 
(If Yes, Give Dates)

Are you now employed? Yes  No 
Are you subject to recall? Yes  No

Please Identify any exceptions and reasons for not contacting prior employers:


Can you travel if a job requires it?  Yes  No

Only U.S. citizens or aliens who have a legal right to work in the U.S. are eligible for employment. Can you, upon employment, submit documentation verifying your legal right to work in the U.S. and your identity? Yes  No

Have you ever been convicted of a felony?  Yes  No
(A conviction will not necessarily disqualify you from employment)
 If Yes, Give dates and explain below...


Do you smoke?  Yes  No

Educational Data
(In Address Box Please Give Number & Street, City, State and ZIP code)

High School Name:    Number of Years Completed:
Address:
                
College Name:     Number of Years Completed:
Address:
Degree:   Major Course of Study:

Other School:    Number of Years Completed: 
Address:
Degree:   Major Course of Study:

  
  Have you had prior educational experience which relates to the job 
  for which you are applying? Yes  No

  If Yes, Describe:
 

  
  Other Skills: List any other job-related skills or 
  qualifications that support your application:
 
          

In order to permit a check of your work and educational records, should we be made aware of any change of name or assumed name that you previously used? Yes  No
If Yes, Identify names and relevant dates:

   Are you a veteran of the U.S. Military Service? Yes  No 
   If Yes, which branch of Service?
   If Yes, Beginning date and ending date of active duty: From:/ to /
   Date of Discharge from Military Service:
   If other than "Honorable", please explain:








 

    
Employment Experience
(Top listing being the most recent)

Employer's Name & Address:
Telephone Number:   Job Title:
Dates: From To     Current Wage:
Supervisor: Reason for Leaving:
Summary of Duties:


Employer's Name & Address:
Telephone Number:   Job Title:
Dates: From To     Current Wage:
Supervisor: Reason for Leaving:
Summary of Duties:


Employer's Name & Address:
Telephone Number:   Job Title:
Dates: From To     Current Wage:
Supervisor: Reason for Leaving:
Summary of Duties:


Have you ever been dismissed or forced to resign from any employment? Yes No
If Yes, Please explain:
List below any other information or remarks that you wish to have considered as part of your application for employment.


Additional Information

Specialized Skills:
CPT  ICD-9 PC  Calculator  Typewriter  FAX  Excel  PBX System  Microsoft Word
List any Production/Mobile Machinery:
Other:


Affirmative Action Survey
Government agencies require periodic reports on the sex, ethnicity, disabled and veteran status of applicants. This data is for analysis and affirmative action only. Submission of information is voluntary and in no way required to complete this application.

Your Sex: Male  Female

Race/Ethnic Group: White    Black    Hispanic  
American Indian/Alaskan Native    Asian/Pacific Islander

Are You A Vietnam Era Veteran:  Yes  No

Notice to Applicants: This employer complies with the Americans with Disabilities Act of 1990. During the interview process, you may be asked questions concerning your ability to perform job-related functions. If you are given a conditional offer of employment, you may be required to complete a post-job offer medical history questionnaire and/or undergo a medical examination. If required, all entering employees in the same job category will be subject to the same medical questionnaire and/or examination and all information will be kept confidential and in separate files.

Applicant's Statement
I certify that all statements made by me on this application are true, complete and correct to the best of my knowledge, and I hereby grant FHCP to verify such information and hereby release the Employer from any liability as a result of such contact. I understand that any false statement or omission of facts called for may be considered as sufficient cause for rejection of this application, or for dismissal if discovered during my employment. A criminal background check will be conducted for all new hires, as well as, Abuse Registry and Motor Vehicle, as required. In addition, if employed, any misrepresentations or omissions of facts called for in this application will be cause for dismissal at any time without any previous notice.
I understand that my employment with my employer is for no specific term and may be terminated by me or the employer with or without notice or cause at any time. I further understand that no oral promise, Employer policy, custom, business practice or other procedure (including The Employer's Human Resources Handbook or any other manuals) constitutes an employment contract or modification of the at-will employment relationship between me and the Employer. I also understand that no supervisor or other official of the Employer (except its Chief Executive Officer, in writing) has the authority to enter into any agreement with me or to make any agreement contrary to the foregoing.
We conduct our business with the highest possible degree of safety and efficiency. Because of this, the Employer may require applicants for employment to undergo blood and/or urinalysis screening for drug use as part of our pre-placement physical examination. In addition, all employees of the Employer are subject to blood tests or urinalysis screening for drug or alcohol use at any time and immediately upon request of the employer.
This application, for the position you applied for, will remain active for ninety (90) days. Any applicant wishing to be considered for employment beyond ninety (90) days should reapply.

ELECTRONIC SUBMISSION OF THIS FORM IS REGARDED AS ATTESTATION BY APPLICANT THAT THE FOREGOING INFORMATION IS COMPLETE AND TRUTHFUL. IF THIS APPLICATION LEADS TO AN INTERVIEW AND/OR MORE DETAILED CONSIDERATION FOR EMPLOYMENT, AN APPLICANT STATEMENT WILL NEED TO BE REVIEWED AND A SIGNATURE REQUIRED.
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