Employment Application

Thank you for your interest in working at Family Health Services.

Complete the form below to apply for employment and, if appropriate, upload your resume. Note that your application is not considered complete until you hear from us, either via email or phone.

Note that this form cannot be saved, closed, or reopened during completion. If you prefer, you may download or print this application form in PDF format.

Fields marked with * are required. 

Which position are you applying for?   *
Personal Information
Full Name
(last, first, middle) 		*
Address *
 
City *
State/Province *
Zip/Postal Code *
Home Phone *
Cell Phone
Best Time to Contact You at Home? *
Email *
Are you bilingual? Yes    No   *
What languages other than English do you speak and write fluently?
Are you currently employed? Yes    No   *
If yes, in what capacity?
Date Available for Work *
Do you have a valid driver's license? Yes    No   *
Are you related to anyone working for FHS? Yes    No   *
If yes, in what department is your relative employed?
Name of relative?
Relationship of relative?
Do you have an immediate family member who serves on the FHS Board of Directors? Yes    No   *
 
If you answered yes, depending on relationship, you may be ineligible to work for FHS.
Education
Do you have a high school diploma or equivalency? Yes    No   *
College/University Attended Years Attended
Major Degree Received
College/University Attended Years Attended
Major Degree Received
College/University Attended Years Attended
Major Degree Received
Other Job-Related Training
Professional Licenses or Certificates
Please list any additional information you wish to provide concerning your qualifications for this position:
Experience
List your present and most recent job first. Carefully account for all recent employment (at least the last 10 years, if possible).
May we contact your present employer? Yes    No   *
If no, explain:
Position 1   From   To    Hours per Week *
Employer Name Supervisor Name
Address Phone
  No. Supervised
Salary $ per
Reason for Leaving
Duties of Your Position
Position 2   From   To    Hours per Week
Employer Name Supervisor Name
Address Phone
  No. Supervised
Salary $ per
Reason for Leaving
Duties of Your Position
Position 3   From   To    Hours per Week
Employer Name Supervisor Name
Address Phone
  No. Supervised
Salary $ per
Reason for Leaving
Duties of Your Position
Professional References
Do not include family members.
Reference Name *
Reference Occupation *
Reference Phone *    Best Time to Call  *
Reference Name *
Reference Occupation *
Reference Phone *    Best Time to Call  *
Reference Name *
Reference Occupation *
Reference Phone *    Best Time to Call  *
Additional Information and Optional Resume Upload
Provide any additional information such as other employers or education here, or upload your resume below.

If you upload your resume, please first save it in .pdf, .doc, or .docx format only, using your last and first name. For example: SmithJane.pdf.
Upload Resume
Optional
Please take a moment to answer the following optional question — your response will help us assess how effective our recruitments efforts were for this position:
How did you hear about this employment opportunity?  
If other, please list:
Application Submission
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Enter Security Code:
By clicking the Submit button, you hereby certify that all statements made in this application are true and complete to the best of your knowledge and you understand that false statements are cause for rejection of application, removal of your name from eligible list or dismissal from your position.
   

 

Family Health Services is an equal opportunity employer. We encourage all persons to file applications with us and we do not discriminate on the basis of race, color, religion, age, sex, national origin, veteran status and mental or physical disability.

All job offers are contingent upon the successful completion of a background process, which may include a police records check and a medical examination that includes drug screening.

For further information, please contact us.