Apply with APHCA

General Information

Alabama Primary Health Care Association is an equal opportunity employer. This application will not be used for limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Applicants requiring reasonable accommodation in the application and/or interview process should notify a representative of the organization.

Name *

First

Last

Date

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email *

Position applying for *

Date Available to Start *

Are you 18 years of age or older? *

Yes
No

Can you prove that you are a U.S. citizen or that you can legally work in the U.S.? *

Yes
No

How were you referred to APHCA? *

Have you ever applied or worked for APHCA before? *

Yes
No

If yes, state when and what position:

Do you know of any friends, relatives, or acquaintances working for APHCA? *

Yes
No

If yes, state name and the nature of relation:

Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation? *

Yes
No

If no, describe the functions that cannot be performed:

Have you ever been convicted of a criminal offense (misdemeanor or felony)? *

Yes
No

If yes, please describe the crime—state the nature of the crime (when and where convicted and disposition of the case):

Education/Training/Military

High School/GED:

Location

Did you graduate?

Yes
No

Diploma/Major

College/University:

Location

Did you graduate?

Yes
No

Diploma/Major

Other Institution:

Location

Did you graduate?

Yes
No

Diploma/Major

Languages read, written, or spoken fluently other than English: *

Other credential/license/professional affiliations, etc., which are relevant to the job for which you are applying:

Military

Branch of Service:

Time in Service:

Highest Rank Obtained:

Specialty:

Include any military training, special honors, skills/duties, or service schools attended:

Employment History (Include voluntary/internship experience)

Recent Employer: *

Phone *

From (Month/Year) To (Month/Year) *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Supervisor *

Hours per week *

Position Title & Description *

Last Salary *

Reason for leaving *

May we contact this employer? *

Yes
No

Employer:

Phone

From (Month/Year) To (Month/Year)

Address

Address Line 1

Address Line 2

City

State

Zip Code

Supervisor

Hours per week

Position Title & Description

Last Salary

Reason for leaving

May we contact this employer?

Yes
No

Employer:

Phone

From (Month/Year) To (Month/Year)

Address

Address Line 1

Address Line 2

City

State

Zip Code

Supervisor

Hours per week

Position Title & Description

Last Salary

Reason for leaving

May we contact this employer?

Yes
No

Provide references not related to you. *

Name/ Address/ Telephone/ Occupation

Provide references not related to you.

Name/ Address/ Telephone/ Occupation

Provide references not related to you.

Name/ Address/ Telephone/ Occupation

Resume

READ CAREFULLY: I certify that the information contained in this application for employment is true to the best of my knowledge. I understand that any misstatement or omission of information may result in denial of employment or may be sufficient cause for dismissal. I hereby authorize Alabama Primary Health Care Association to investigate the truthfulness of all statements made on this application regarding educational and employment history, misdemeanors or felonies specified, listed references, and any other persons who can verify information.

Authorization Signature of Applicant

Date