Order Number Personal Information Title Choose One Mr. Ms. Mrs. Prof. Dr. First Name * Last Name * Address * City * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Zip Code * Phone Number * Email Address * Position of Interest Position You Are Applying For * Select One Example Position 1 Example Position 2 Available Start Date * Upload Resume and Cover Letter Upload Cover Letter * Upload Resume * Education School Name School Name School Name School Name Years Completed Years Completed Years Completed Years Completed Degree Received Degree Recieved Degree Recieved Degree Recieved Major Major Major Major Licenses and Certifications License / Certification Type License / Certification Type License / Certification Type License / Certification Type License Number License Number License Number License Number Issued By Issued By Issued By Issued By Issue Date Issue Date Issue Date Issue Date Employment History Employer Employer Employer Employer Address Address Address Address Position / Job Title Position / Job Title Position / Job Title Position / Job Title Start Date Start Date Start Date Start Date End Date End Date End Date End Date Ending Pay Rate Annual or Hourly Annual or Hourly Annual or Hourly Eligibility and Background Are you currently eligible to work in the United States of America? * Yes No If selected for an interview, I give my consent to the Greater Flint Health Coalition to contact my supplied references and to conduct a background check? * Yes No Are you aware of any potential conflicts of commitment (such as an outside job you would maintain if hired) or conflicts of interest (such as a current contract you hold)? * Yes No Have you ever been convicted of any misdemeanor or felony, including alcohol or drug-related driving offenses? Driving convictions such as operating while intoxicated, operating in the presence of drugs, operating without a license, etc., are generally misdemeanors or felonies and should be included. * Yes No Note: A yes response does not automatically disqualify a job applicant from further consideration. Each applicant is evaluated individually, based on a number of factors including the nature of the crime, how long ago the crime and/or release from incarceration occurred, whether a sufficient or satisfactory work record has been established since the crime and/or release from incarceration, and the criteria of the position applied for. Do you have any felony charges pending? * Yes No Note: A yes response does not automatically disqualify a job applicant from further consideration. Each applicant is evaluated individually, based on a number of factors including the nature of the crime, how long ago the crime and/or release from incarceration occurred, whether a sufficient or satisfactory work record has been established since the crime and/or release from incarceration, and the criteria of the position applied for. References First Name * First Name First Name Last Name * Last Name Last Name Years of Acquaintance * Years of Acquaintance Years of Acquaintance Company, Title * Company, Title Company, Title Phone Number * Phone Number Phone Number Reference Type * select one Personal Professional Reference Type select one Personal Professional Reference Type select one Personal Professional All information provided within this application will be kept confidential. Information Summary
