Apply Now We want to hear from you! Please apply below or e-mail us at info@communityclinicnwa.org. Step 1 of 7 14% APPLICANT INFORMATIONLast Name(Required) First Name(Required) Middle Initial Address(Required) Street Address Apartment/Unit # City(Required) State(Required)AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZIP(Required) Phone(Required)Email(Required) Position Applied for(Required) Desired Salary(Required) Are you authorized to work in the U.S.?(Required) Yes No Have you ever worked for this company?(Required) Yes No If so, when?(Required) Have you ever been convicted of a felony?(Required) Yes No If yes, explain:(Required) Are any of your friends or relatives employed here?(Required) Yes No If Yes, Name & Location:(Required) Do you smoke or use tobacco products:(Required) Yes No EDUCATIONHigh School Address Did you graduate? Yes No Degree College Address From To Did you graduate? Yes No Degree Other Address From To Did you graduate? Yes No Degree Bilingual? Yes No Languages Spoken: REFERENCESPlease list three professional referencesReference 1Full Name Email Company PhoneAddress Relationship Reference 2Full Name Email Company PhoneAddress Relationship Reference 3Full Name Email Company PhoneAddress Relationship PREVIOUS EMPLOYMENTReference 1Company PhoneFaxSupervisor Email Address Job Title Starting Salary Ending Salary Responsibilities From To Reason for Leaving May we contact your previous supervisor for a reference? Yes No Reference 2Company PhoneFaxSupervisor Email Address Job Title Starting Salary Ending Salary Responsibilities From To Reason for Leaving May we contact your previous supervisor for a reference? Yes No Reference 3Company PhoneFaxSupervisor Email Address Job Title Starting Salary Ending Salary Responsibilities From To Reason for Leaving May we contact your previous supervisor for a reference? Yes No RECRUITMENT SOURCEEmployee Referral: Advertisement: If other, explain: DISCLAIMER AND SIGNATURECheck Disclaimer Below(Required) I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.Signature MORE INFORMATIONWhat prompted you to apply for this position?Please describe what would make you a good candidate for this position.Upload ResumeAccepted file types: jpg, png, pdf, docx, Max. file size: 100 MB.
