Application for Employment

Position(s) Applied for:
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Telephone #*
Other Telephone #
Email*
Are you over the age of 21?*
- Yes
- No
STOP! You Must be Over 21 to work at Green Hills Patient Center.
I understand that I do not meet the age requirements to work at Green Hills Patient Center. I would like you to keep my information on file.
In order to be employed by Green Hills Patient Center, you must be 21 years of age or older.
Do you have a valid Arizona Driver License?*
- Yes
- No
STOP! You Must have a valid Arizona Driver License to work at Green Hills Patient Center.
I understand that I do not meet the requirements to work at Green Hills Patient Center. I would like you to keep my information on file.
In order to be employed by Green Hills Patient Center, you must have a valid Arizona Driver License.
Have you ever been employed here before?
- Yes
- No
If yes, give dates and positions:
Date available for work:
MM slash DD slash YYYY
What is your desired hourly rate?
Type of employment desired:
- Full-time
- Part-time
Are you able to meet the attendance requirements of this position?
- Yes
- No
Have you ever pled 'guilty' or 'no contest' to, or been convicted of a crime?
- Yes
- No
If yes, please provide date(s) and details:
Answering “yes” to these questions does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be considered.
Employment History
Provide the following information of your past three (3) employers, assignments, or volunteer activities, starting with the most recent.
From:
MM slash DD slash YYYY
To:
MM slash DD slash YYYY
Employer:
Telephone #
Starting Job Title:
Ending Job Title:
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Immediate Supervisor & Title:
Summarize the nature of work performed & job responsibilities:
May we contact for reference?
- Yes
- No
- Later
Date we could contact:
MM slash DD slash YYYY
Reason for leaving:
Hourly rate/salary: Starting
Hourly rate/salary: Final
Employment History Two
From:
MM slash DD slash YYYY
To:
MM slash DD slash YYYY
Employer:
Telephone #
Starting Job Title:
Ending Job Title:
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Immediate Supervisor & Title:
Summarize the nature of work performed & job responsibilities:
May we contact for reference?
- Yes
- No
- Later
Date we could contact:
MM slash DD slash YYYY
Reason for leaving:
Hourly rate/salary: Starting
Hourly rate/salary: Final
Employment History Three
From:
MM slash DD slash YYYY
To:
MM slash DD slash YYYY
Employer:
Telephone #
Starting Job Title:
Ending Job Title:
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Immediate Supervisor & Title:
Summarize the nature of work performed & job responsibilities:
May we contact for reference?
- Yes
- No
- Later
Date we could contact:
MM slash DD slash YYYY
Reason for leaving:
Hourly rate/salary: Starting
Hourly rate/salary: Final
Skills & Qualifications:
Skills & Qualifications:
Summarize any training, skills, licenses and/or certificates that may qualify you as being able to perform job-related functions in the position for which you are applying.
Educational Background:
High School:
Name and Location:
Number of Years Completed:
Did you graduate?
Course of Study:
College:
Name and Location:
Number of Years Completed:
Did you graduate?
Major:
Degree:
Other:
References (include three):
Please include: Name, Company & Address; Telephone #; # of Years Known
Upload Your Cover Letter & Resume:
Acceptable file types: pdf, doc, docx, pages
Acceptable file types: pdf, doc, docx, pages
Drop files here or

Accepted file types: doc, docx, pdf, pages, Max. file size: 4 MB, Max. files: 2.
Applicant Statement*
I certify that all information I have provided is true, complete, and correct. I understand that any information found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) cancel further consideration of this application, or (ii) immediately discharge me from service, whenever it is discovered. I expressly authorize Green Hills Patient Center, Inc. its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding Green Hills Patient Center, Inc. its agents, employees or representatives, for seeking, gathering and using such information in the employment persons, corporations process and all other or organizations for furnishing such information about me.
I understand that Green Hills Patient Center, Inc. does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state or federal law.
I understand that this application remains current for only 30 days.
If I am hired, I understand that I am free to resign and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the Green Hills Patient Center, Inc. is authorized to make any assurances to the contrary and that no implied, oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the CEO of Green Hills Patient Center, Inc.
I understand that if I am hired, I will be required to provide proof of identify and legal authority to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.
Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of Green Hills Patient Center, Inc.
I certify that I have read, fully understand, and accept all terms of the Applicant Statement.

Employment History

Employment History Two

Employment History Three

Skills & Qualifications:

Educational Background:

References (include three):

Upload Your Cover Letter & Resume:

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Employment History

Employment History Two

Employment History Three

Skills & Qualifications:

Educational Background:

References (include three):

Upload Your Cover Letter & Resume:

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Be Inspired!

The Show Low Low Down