Employment Application

Please check this box to indicate that you agree to the RSBCIHI employment application policies. *

I agree.

Position Applying For: *

Email *

Name *

First

Middle

Last

Date of Birth *

Social Security Number

Drivers License Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Are you authorized to work in the USA?

YES
NO

Are you fully vaccinated with booster? *

YES
NO

If employed and under 18, can you furnish a work permit?

YES
NO

Have you filed an application here before?

YES
NO

Have you ever been employed here before?

YES
NO

Can you travel if the job requires it?

YES
NO

Are you available to work nights and weekends if required?

YES
NO

Are you employed now?

YES
NO

Are you on a lay-off and subject to recall?

YES
NO

May we contact your previous/present employer(s)?

YES
NO

Are you a member of the Reserves, and subject to recall?

YES
NO

To your knowledge, are you an immediate relative of any member of the Board of Directors of Riverside-San Bernardino County Indian Health, Inc.?

YES
NO

Have you been convicted of or plead guilty to or no contest (no lo contendre) to an offense involving crimes of violence?

YES
NO

If YES, please explain.

Date you can start:

List professional, trade, business or civic activities and offices held. (Exclude those which indicate race, color, religion, sex or national origin):

Can you perform the essential functions of this job with or without accommodations?

YES
NO

Education Record

High School

Graduation Date

Degree

Business or Technical School

Date Attended

Degree, Major

Undergraduate College

Date Attended

Degree, Subject

Graduate School

Date Attended

Degree, Subject

Work History

(give information about your last 3 jobs, starting with the most recent)

Employer #1

Dates Employed

Address

Address Line 1

Address Line 2

City

State

Zip Code

Title / Duties

Reason for Leaving

Ending Salary

___________________________

Employer #2

Dates Employed

Address

Address Line 1

Address Line 2

City

State

Zip Code

Title / Duties

Reason for Leaving

Ending Salary

___________________________

Employer #3

Dates Employed

Address

Address Line 1

Address Line 2

City

State

Zip Code

Title / Duties

Reason for Leaving

Ending Salary

___________________________

SUMMARIZE SPECIAL SKILLS AND QUALIFICATIONS ACQUIRED FROM EMPLOYMENT OR OTHER EXPERIENCE

State any additional information you feel may be helpful to us in considering your application

Signature *