United Indian Health Services, Inc.
1600 Weeot Way, Arcata, CA 95521 (707) 825-5000 Fax (707) 825-6747

APPLICATION FOR EMPLOYMENT

PERSONNEL INFORMATION
Date:
Name:
Names used in the past:

Telephone
SSN:
Address:
 
Street
City
State
Zip
Number of years at present address:      
Residence address during the past ten years:      
 
 
Street
City
State
Zip
 
 
Street
City
State
Zip
 
 
Street
City
State
Zip
Are you over 18? Yes No
Must be 21 or older in order to be covered by agency vehicle insurance. Cannot drive for any agency purpose if not covered by agency insurance. Are you 21 or older? Yes No
If hired, do you have a reliable means of transportation to get to work? Yes No
Have you ever been convicted of a felony? (Do not include marijuana related convictions, which occured more than two years prior to the date of application.) Yes No
If yes, please explain:
 
(A conviction will not necessariy disqualify you from employment.)

EMPLOYMENT DESIRED
Position:
Date Available:
Salary Desired:
Have you ever applied to UIHS?
Yes No
Date:
Have you ever worked for UIHS? Yes No
Dates:
      
Are you presently employed? Yes No If yes, may we contact your present employer? Yes No
Are you available to work: Full-time Part-time Temporary Per-Diem
How were you referred to UIHS? Newspaper Ad Internet Employee Referral In-house Posting
Other (Please specify)
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EDUCATION AND TRAINING
School Name & Location
Years Attended
Graduate
What Degree
Major Subject/
Total (if applicable)
High School/GED:
Yes No
Technical School:
Yes No
College/University 1:
Yes No
College University 2:
Yes No
College University 3:
Yes No
Highest Degree Earned: High School Associate Bachelor Master Doctorate
Typing
wpm
Overall Computer Knowledge
Basic Intermediate Advanced
 Other Ccomputer Programs requiring special skills:
Have you ever served in the military? Yes No If yes, please state branch and unit and describe any special traing or skills:
Describe any specialized training, apprenticeship, skiill or extracurricular activities that are relevant to the job for which you are applying.
Describe any honors, scholarships, appointments or awards that you have received
State any additiona information you feel may be helpful to us in considering your application
indicate any foreign languages you can speak, read and/or write:
List professional, trade business or civil activities and office held
You may exclude information that would reveal sex, race, national origin, age or disability or other protected status or personal information

List any professional or vocational certificates, licenses, or registration that you currently hold or have held in the past

List any job-related professional or technical organization to which you belong.

Driver's License Information (Must be Complete)
State: Number Expiration Date:
Class:    

Restrictions or Suspensions (respond fully if driving is required by the job for which you are applying)
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GENERAL INFORMATION

Are you able to perform the duties of the position for which you are applying, including regular attendance, without a reasonable accomodation? (If youneed an explanation for the meaning of "reasonable accomodation", please contact the Human Resources Division). Yes No

Can you travel if the job requires it? Yes No
Travel can be for overnight and extended periods (up to three (3) weeks).

Did you recieve written performance evaluations from any of your prior employers? Yes No

If so, please list the employers what did such evaluations, describe the frequency of such evaluations, and check the appropriate box indicatinng whether you signed such evaluations.

Employer
Frequency of evaluations
(e.g., annual, bi-annual, etc.)
Signed?
Yes No
Yes No
Yes No

Have you ever been discharged from an employer? Yes No - Explain Reason

Explain any gaps in your employment history. (Do not provide information about any physical or mental disabilities or other medical information.)

What do you expect to be doing in five years?


 What would your last manager/supervisor say about your job performance?
What has been your favorite/most interesting job?
 What mad it enjoyable/interesting?
What job did you dislike the most?

Why did you dislike it?
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EMPLOYMENT DATA - (MUST BE COMPLETED) or application will not be considered
Start with your present or last job. Include any job-related military service assignments and volunteer activities.
Company Name Phone No.
Dates of Employment
From (Mo/Yr)
To (Mo/Yr)
Address (Include Street, City, State, Zip Code)

Job Title - Start

Job Title - Final
Base Rate of Pay
Start
Final
Supervisor (Name/Title)
Description of Job Duties:
Reason for Leaving: F/T P/T Hrs/Wk
H/R Use Only

Applicable Exp.
Yes No

Total Length of Service




Company Name Phone No.
Dates of Employment
From (Mo/Yr)
To (Mo/Yr)
Address (Include Street, City, State, Zip Code)

Job Title - Start

Job Title - Final
Base Rate of Pay
Start
Final
Supervisor (Name/Title)
Description of Job Duties:
Reason for Leaving: F/T P/T - Hrs/Wk
H/R Use Only

Applicable Exp.
Yes No

Total Length of Service




Company Name Phone No.
Dates of Employment
From (Mo/Yr)
To (Mo/Yr)
Address (Include Street, City, State, Zip Code)

Job Title - Start

Job Title - Final
Base Rate of Pay
Start
Final
Supervisor (Name/Title)
Description of Job Duties:
Reason for Leaving: F/T P/T - Hrs/Wk
H/R Use Only

Applicable Exp.
Yes No

Total Length of Service




Company Name Phone No.
Dates of Employment
From (Mo/Yr)
To (Mo/Yr)
Address (Include Street, City, State, Zip Code)

Job Title - Start

Job Title - Final
Base Rate of Pay
Start
Final
Supervisor (Name/Title)
Description of Job Duties:
Reason for Leaving: F/T P/T - Hrs/Wk
H/R Use Only

Applicable Exp.
 Yes No

Total Length of Service




Reference Data
(List Three Professional References that UIHS may contact - Must be Completed.)
Name Business Relationship Contact Telephone Number
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  1. I understad that any offer of employment will be conditioned on my passing a medical examination, including durg and alcohol testings, and that a positive drug and/or alcohol test will result in rejection of my employment application and withdrawal of the conditional offer of employment.


  2. I understand that any offer of employment will be conditioned upon my passing a Criminal History Background Check and Character Investigation. I may be hired prior to these checks being returned but I understand that I will not be allowed to have unsupervised contact with children until these checks are completed.


  3. If I am offered employment, I will, as a condition of employment, be required to submit proof of my identity and legal right to work in the U.S.


  4. I understand that, if I am employed, any false statement, misrepresentation, or omission of facts on this application or on any supporting documents, regardless of when, how, or in what context discovered to be false or omitted, may result in my immediate dismissal.


  5. I understand that I will be required to possess a current valid driver's license, and provide valid vehicle insurance if my job requires me to drve in the course of my work. If I am under 21 years of age, I will not be allowed to drive for any reason.


  6. I understand and agree that, if I am offered a position, it will be offered on condition that my employment shall be at will and ffor no definite period. I understand and agree that United Indian Health Services, Inc. may terminate my employment at any time, with or without cause, and with or without notice, at my option or the option of United Indian Health Services, Inc.


  7. I understand that no supervisor or manager may alter or amend the conditions set forth in paragraphss one (1) through six (6) above. I understand that the foregoing conditions may only be altered or amended by a written agreement signed by the Executive Director of United Indian Health Services, Inc.

My signature below certifies that I have read and understand the foregoing and to the best of my knowledge and belief, the informatin on this form is true and correct.

Signature:

Date:

If claiming American Indian Preference - Proof of membership MUST BE ATTACHED, if verification is not attached you will not fall under Indian Preference. HR will not contact patient registration for verification.

Tribal Affiliation:

Tribal and/or BIA Enrollment No.

Agency:

PREFERENCE will be given to American Indian as set forth under PL 93-638. If claminig California descendent, please attach birth certificate. Attach photocopy of tribal identification card or letterof Membershiip on Tribal stationary. Current agency records may not be used by UIHS to verify enrollment.