Community Healthcare Center of Wichita Falls - Online Employment Application

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Required fields are in red.

General Information

Position Sought

First Name:

Last Name:

Present Address:

	Street:		City:
	State:		Zip:

Previous Address:

	Street:		City:
	State:		Zip:

Current Telephone:

If you are presently employed may we contact your employer?

Yes

Are you eligible to work in the US?

Yes

Salary Expected:

Date Available:

Person to Contact In Case of Emergency

	Name:		Address:
	Day Phone:		Night Phone:

Referral Source (e.g., newspaper, school, walk-in, current employee - be specific)

Have you ever applied to or worked at the Center?

Yes

Position:

Dates:

Are there any limitations to your work hours?

Yes

If yes please explain:

	Will you work evenings if necessary?	Yes		No
	Will you work Saturday/Sunday if necessary?	Yes		No

Have you ever been convicted or sentenced to deferred adjudication for a criminal offense (felony and/or misdemeanor)?

Yes

If yes, please explain (date and type of offense(s): (Convictions will not necessarily exclude you from employment, but will be reviewed in light of circumstances, including age, date, and nature of violation)

Relatives Employed by the Center

Name:

Relationship:

Education

High School

Name of School:

City & State:

Course of Study:

Last year completed:

Diploma/Degree:

Grade Avg.

College

Name of School:

City & State:

Course of Study:

Last year completed:

Diploma/Degree:

Grade Avg.

Post - Graduate

Name of School:

City & State:

Course of Study:

Last year completed:

Diploma/Degree:

Grade Avg.

Other

Name of School:

City & State:

Course of Study:

Last year completed:

Diploma/Degree:

Grade Avg.

Extracurricular activities: (exclude activities relating to race, religion, national origin, gender, age, or disability)

Leadership Positions Held: (exclude activities relating to race, religion, national origin, gender, age, or disability)

Military Experience

Service Branch:

Dates:

Rank at Discharge:

Type of Discharge:

Skills Acquired:

Business Experience

Present or Most Current Employer

Employer:

From:

To:

Street Address:

Telephone:

City:

State:

Zip Code:

Wage/Salary:

Your Position:

Reason for Leaving:

Previous Employer

Employer:

From:

To:

Street Address:

Telephone:

City:

State:

Zip Code:

Wage/Salary:

Your Position:

Reason for Leaving:

Previous Employer

Employer:

From:

To:

Street Address:

Telephone:

City:

State:

Zip Code:

Wage/Salary:

Your Position:

Reason for Leaving:

Previous Employer

Employer:

From:

To:

Street Address:

Telephone:

City:

State:

Zip Code:

Wage/Salary:

Your Position:

Reason for Leaving:

Present or Most Current Employer

Employer:

From:

To:

Street Address:

Telephone:

City:

State:

Zip Code:

Wage/Salary:

Your Position:

Reason for Leaving:

Have you ever been discharged or asked to resign from any position?

Yes

If yes please explain:

Please explain all periods of unemployment:

Do you have any other job that you would expect to continue if employed here?

Yes

If yes please explain:

Please list any other businesses or companies in which you are involved or have financial interest:

Personal References

List four individuals who can discuss your work and job performance.

	Name:		Company:
	Phone:

	Name:		Company:
	Phone:

	Name:		Company:
	Phone:

	Name:		Company:
	Phone:

Acknowledgment - Read Carefully

I certify that the facts set forth in my application and any resume I have submitted are true and correct. I understand that any false statements, misrepresentation, or omissions on this application, my resume, or any other Center document shall be considered a sufficient basis for rejection of my application and for my dismissal if hired, regardless of when discovered. In the event of my employment with the Center, I agree to conform to the rules and the regulations of the Center at any time and acknowledge that these rules and regulations may be changed, interpreted, withdrawn, or added to by the Center at any time, at the Center’s option and without prior notice to me. I understand that this application will be given every consideration, but its receipt does not imply that I will be employed. I also understand that if I am employed, my employment will be at-will, meaning that employment may be terminated by me or the company for any or no reason, with or without cause, at any time. I further understand that nothing in this application is to be considered in any way as a contract for employment. I acknowledge and agree that any statement or representation, whether written or oral, past or present, which is contrary to my right and the Center’s right to an at-will employment relationship is void and unenforceable and should not be relied upon in the absence of a written contract of employment signed by the Executive Director. I hereby authorize the Center to conduct any investigation it deems necessary regarding my application. I also hereby authorize the Center to gather and to release information about me, together with their opinion on these matters, without any liability for any damage whatsoever caused either directly or indirectly by giving or receiving such information or opinions. I authorize any former employer, present employer, schools, colleges, and universities, personal references and/or any other person or persons, to disclose to the company any information or opinions they may have concerning me, my character, or my employment record. I hereby unconditionally release the Center, any former employers, their agents and employees, and all references listed above from any and all claims, demands or liabilities arising out of or related to such investigation or disclosure, including liability arising from negligence. I understand that the Center may, in the course of its investigation of my application, obtain an investigative consumer report on me, as defined in the Fair Credit Reporting Act, and I understand that such a report may include information as to my character, general reputation, personal characteristics, working skills and abilities, and mode of living. I understand that the Center is required to furnish to me upon proper request and within reasonable time, according to the law, the nature and scope of the investigation.

Upload resume with application:

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	Community Healthcare Center
	200 Martin Luther King Jr. Blvd.
	Wichita Falls, Texas
	76301

	CHC - Juarez Medical Clinic
	1000A Juarez St.
	Wichita Falls, Texas
	76301

	Medical: (940) 766-6306
	Dental: (940) 322-4297

	Mailing Address:
	P.O. Box 720
	Wichita Fall, Texas
	76307-0720

	Corporate Fax: (940) 761-1698
	Records Fax: (940) 766-6504

Se habla español

www.chcwf.com

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