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1511 Christy Drive Jefferson City MO 65101
Call: 573-632-2777

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Job Application

Please fill out all the required fields and attach your resume below.

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Birth Date

Home Phone *

Cell Phone

Email *

Position Applying For

Employment Desired *

Full-Time
Part-Time
Either

How man hours can you work weekly?

Can you work nights? *

Yes
No

Are you 18 or older? *

Yes
No

Available Start Date *

Salary Desired

Have you ever been convicted of a felony? *

Yes
No

I certify that I am a U.S. citizen, permanent resident, or a foreign national with authorization to work in the United States. *

Yes
No

How did you find out about this position? *

Current Employee
Career Fair
Newspaper Ad
Radio/TV Ad
Search Engine
Other

How did you find out about this position? (If Other)

Upload your resume

Please only upload .pdf files.

Upload a cover letter (optional)

Please only upload .pdf files.

Additional info (optional)

Employment History

Employer Name

Employer Address

Address Line 1

Address Line 2

City

State

Zip Code

Starting Date

Ending Date

Can we contact this employer?

Yes
No

Employer Name 2

Employer Address 2

Address Line 1

Address Line 2

City

State

Zip Code

Starting Date

Ending Date

Can we contact this employer?

Yes
No

Employer Name 3

Employer Address 3

Address Line 1

Address Line 2

City

State

Zip Code

Starting Date

Ending Date

Can we contact this employer?

Yes
No

References

Name

Phone

Relationship

Reference 2

Name

Phone

Relationship

Reference 3

Name

Phone

Relationship

Education and Skills

Please list all education beginning with the most recent. Indicate a diploma or degree, if completed including GED if obtained.

College

Name of School

Location

City and State

Degree or Major

Years Completed

Did you graduate?

Yes
No

Education and Skills Continued

College

Name of School

Location

City and State

Degree or Major

Years Completed

Did you graduate?

Yes
No

Education and Skills Continued

High School

Name of School

Location

City and State

Degree or Major

Years Completed

Did you graduate?

Yes
No

Office/Computer Skills

Typing

Words per minute

Checkboxes

Microsoft Word
Microsoft Excel
Microsoft Outlook
Multiline Phone
Medical Terminology

Check the software/applications you are familiar with

Please list any skills/credentials you feel are relevant to this position:

Degrees/Certifications held:

Issuing Authority

License/Certification #

Effective Date

Expiration Date

Degrees/Certifications held:

Issuing Authority

License/Certification #

Effective Date

Expiration Date

Degrees/Certifications held:

Issuing Authority

License/Certification #

Effective Date

Expiration Date

Please read carefully and sign- I certify the above statements are correct. I understand that my false information (or omissions) in the application, or its supporting documents, will be sufficient grounds for refusal to hire me or termination without notice. I agree that all rules, orders and regulations of the Board of Directors affecting my employment shall constitute a part of my appointment or employment. I further understand that Community Health Center of Central Missouri has the right to review my education, previous employment, driving and criminal records and other background data. This application will be considered valid for 6 months from date signed.

Checkboxes *

Yes

Website

Patient Information

Insurances Accepted
Appointments
Patient Portal
Patient Rights
Payment Options
Forms
Patient Concern or Grievance Report

Patient Portal

Pay a Bill

After Hours Care

Jefferson City Clinic

1511 Christy Drive
Jefferson City, MO 65101

Phone 573-632-2777
Fax 573-632-2769

Linn Clinic

316 W. Main Street
Linn, MO 65051

Phone 573-632-2777
Fax 573-897-4941

California Clinic

606 E Buchanan St
California, MO 65018

Phone 573-632-2777
Fax 573-796-2614

Fulton Clinic

561 Commons Drive
Fulton, MO 65251

Phone 573-632-2777
Fax 573-826-2777

© 2019 Community Health Center of Central Missouri

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