Job Application

ALLIANCE FOR AFRICAN ASSISTANCE
5952 El Cajon Blvd. San Diego,CA 92115
Tel:(619) 286-9052 Fax: (619) 286-9053

Dear our friend

Thank you for your interest in helping the Alliance Health Clinic. Please print and complete this form, make your check payable to "Alliance Health Clinic" and mail it along with your payment to: Alliance Health Clinic - 5952 El Cajon Blvd San Diego CA 92115.

Dear our friend

Last Name First Name Middle Name

Address Number Street City State Zip Code

Telephone Number(s)

Social Security Number

- -

Do you have a valid California Driver’s License? ____ Yes ____ No Do you have any major traffic violation? ___ Yes ___ No

If yes, explain:__________________________________________________________________

Are you legally eligible for employment in the USA? Yes___ No___ (If yes, verification will be required)

Are you of the legal age to work? ______ On what date would you be available to work ____/_____/_____

Are you available to work? ____ Full Time____ Part Time____ Shift Work____ On Call____ Temporary

Have you ever been employed with us before? _____Yes _____No (If yes, give date _____/_____/_____)

List any friends or relatives working for us: __________________________________________________________

Are you currently on “Lay-Off” status and subject to recall? _____Yes _____No

Have you been convicted of a felony within the last 7 years? _____Yes _____No

(Conviction will not necessarily disqualify an applicant from employment)

If yes, please explain: _____________________________________________________________________________

Some positions require finger print clearance through the department of Social Services. All offers of employment are

contingent on application passing a pre-employment drug/alcohol screening.

Employment Experience

Start with your present or last job. Include any job-related military service assignments and volunteer activities.

You may exclude organizations, which indicate race, color, religion, gender, national origin, handicap or other protected status.

1	Employer	Date Employed		Work Performed
		From	To
	Address
	Telephone Number(s)	Hourly Rate/Salary
		Starting	Final
	Job Title Supervisor
	Reason for Leaving
2	Employer	Date Employed		Work Performed
		From	To
	Address
	Telephone Number(s)	Hourly Rate/Salary
		Starting	Final
	Job Title Supervisor
	Reason for Leaving
3	Employer	Date Employed		Work Performed
		From	To
	Address
	Telephone Number(s)	Hourly Rate/Salary
		Starting	Final
	Job Title Supervisor
	Reason for Leaving
4	Employer	Date Employed		Work Performed
		From	To
	Address
	Telephone Number(s)	Hourly Rate/Salary
		Starting	Final
	Job Title Supervisor
	Reason for Leaving

If you need additional space, please continue on a separate sheet of paper.

Special Skills and Qualifications

Summarize special job-related skills and qualifications acquired from employment or other experience.

_____________________________________________________________________________________________________________

Education

	Elementary School		High School		Undergraduate College/University		Graduate Professional
School Name and Location
Years Completed	4 5 6 7 8		9 10 11 12		1 2 3 4		1 2 3 4
Diploma/Degree
Describe Course of Study
Describe any specialized training, apprenticeship skills and extra curricular activities
Describe any honors you have received
State any additional information you feel may be helpful to us in considering your application
Indicate any foreign languages you can speak, read and/or write
		Fluent		Good		Fair
Speak
Read
Write

List professional, trade, business or civic activities and offices held. You may exclude membership which would reveal sex, race, religion, national origin, age, ancestry, or handicap or other protected status:

References

Give name, address and telephone number of three references that are not related to you and not previous employers.

1. _______________________________________________________________________________________________________

2. ______________________________________________________________________________________________________

3. ______________________________________________________________________________________________________

Have you ever had any job-related training in the United States military? _____ Yes _____ No

If yes, please describe __________________________________________________________________________________

______________________________________________________________________________________________________

Are you physically or otherwise unable to perform the duties of the job for which you are applying? _____ Yes _____No

Applicant's Statement

I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

____________________________________ _______________________

Signature of Applicant Date

FOR PERSONNEL DEPARTMENT USE ONLY

Arrange Interview _____ Yes _____ No

Remarks ______________________________________________________________________________________

______________________________________________________________________________________

Employed _____Yes _____No Date of Employment _____________________________

Job Title _________________________ Salary/Hourly Rate________ Department ______________________

BY______________________________________________________________________________

Name and Title Date

Notes_____________________________________________________________________________

______________________________________________________________________________________________

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