APPLICATION FOR EMPLOYMENT

With PEAK VISTA COMMUNITY HEALTH CENTERS

Instructions: Please complete all sections of this application, even if your resume is attached. When
completed, please be sure to sign and date this application. Please print.

Name________________________________________________ Date ______________________

Address________________________________________________ Phone #___________________
City/State________________________________________________ Zip______________________
Position applied for__________________________________________ Job #__________________

Would you prefer: ___ full-time work? May we contact your current
___ part-time work? employer? Yes or No

Were you employed previously by How did you hear about PVCHC?
Peak Vista Community Health Centers (PVCHC)? ____Internet
____Pikes Peak Workforce
___ Yes: from ________ to ________; ____ No ____Newspaper__________________
____Military base________________
____Other______________________
EDUCATIONAL BACKGROUND:

Name and location of school Graduated? Certificate/Degree

High school __________________________________ Yes No ________________
Business/ Trade __________________________________ Yes No ________________
College/ University __________________________________ Yes No ________________
Graduate/Professional __________________________________ Yes No ________________
List any business or clinical skills you have that are related to the position for which you have applied:
_________________________________________________________________________________
_________________________________________________________________________________

PREVIOUS EMPLOYERS AND THEIR ADDRESSES:

Please list the most recent employer first. Do not skip any period of employment. If needed, additional
entries may be recorded on a separate sheet of paper and attached to this application.

Company Name ___________________________________________Phone ( )______________________

Address_________________________________________________ Employed From _______ to_________
Position_____________________________________ Name of supervisor_____________________________
Reason for Leaving___________________________________________________Last Wage______________
Brief description of work responsibilities (specifically list knowledge, skills, and abilities that you believe
relevant to the position for which you are applying)_________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Company Name __________________________________________ Phone ( )______________________
Address_________________________________________________ Employed From _______ to_________
Position_____________________________________ Name of supervisor_____________________________
Reason for Leaving___________________________________________________Last Wage______________
Brief description of work responsibilities (specifically list knowledge skills abilities that you believe relevant to
the position for which you are applying)_________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Company Name __________________________________________ Phone ( )______________________

Address_________________________________________________ Employed From _______ to_________
Position_____________________________________ Name of supervisor_____________________________
Reason for Leaving___________________________________________________Last Wage______________
Brief description of work responsibilities (specifically list knowledge skills abilities that you believe relevant to
the position for which you are applying)__________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

LICENSES/CERTIFICATIONS HELD:

State Board of Medical Examiners #____________________ Expiration Date _________________

Is this license current and without restriction? ___ Yes ___ No

Colorado Nursing License #____________________________ Expiration Date _________________

Is this license current and without restriction? ___ Yes ___ No

Other Licenses or Certificates___________________________ Expiration Date__________________

______________________________________________Expiration Date__________________
______________________________________________Expiration Date__________________
Is this licensure/certification all current and without restriction? ___ Yes ___ No

BUSINESS/ PROFESSIONAL REFERENCES:

(In addition to direct supervisors indicated above)

1. Name____________________________________________ Phone ( ) __________________________

Address_______________________________________________________________________________

2. Name____________________________________________ Phone ( )___________________________

Address_______________________________________________________________________________

3. Name____________________________________________ Phone ( )___________________________

Address_______________________________________________________________________________
PERSONAL REFERENCES:
(Other than family members or previous employers)

1. Name___________________________________________ Phone ( ) __________________________

Address_______________________________________________________________________________

2. Name___________________________________________ Phone ( )___________________________

Address_______________________________________________________________________________

ADDITIONAL INFORMATION:
Are you 18 years of age or older? ___ Yes ____ No

Can you furnish proof of legal right to work in the United States? ___ Yes ____ No
(Evidence of right to work in the U.S. will be required of all incoming employees.)

Have you ever been convicted of any law violation, including any pleas of “no-contest” or “guilty”? (Exclude
minor traffic violations.) ____ Yes ____ No

If yes, please provide an explanation on a separate piece of paper. (If yes, a conviction will not necessarily
disqualify an applicant from employment.)

JOB APPLICATION DISCLAIMER AND ACKNOWLEDGEMENT:

I certify that the information contained in this application is correct to the best of my knowledge. I understand
that to falsify information is grounds for refusing to hire me, or for discharge should I be hired.

I authorize the investigation of any or all statements contained in my application. I also authorize, whether listed
or not, any person, school, current employer, past employers and organizations to provide relevant information
and opinions (for example, education, criminal, and /or credit background checks), that may be useful in making
a hiring decision. I release such persons and organizations from any legal liability in making such statements.

I understand that any offer of employment by Peak Vista Community Health Centers will be contingent upon
the results of drug screening, background checks and TB test /chest x-ray.

I understand that the Immigration Reform and Control Act of November 6, 1986 requires me to prove the
legality of my residency or citizenship. I am also aware that the failure to provide such proof at the time of
request may legally force my termination

I also acknowledge that my employment may be terminated, or any offer or acceptance of employment
withdrawn, at any time, with or without cause, and with or without prior notice at the option of the company or
myself.

Applicant’s Signature_________________________________________ Date_________________

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PEAK VISTA COMMUNITY HEALTH CENTERS’ CUSTOMER SERVICE STANDARDS

• Make eye contact, smile and greet the patient, visitor or employee immediately.
• Use the patient, visitor or employee’s name.
• Escort patients, visitors or employees to their requested location if possible.
• Immediately approach a patient, visitor or employee who seems to be lost and offer them assistance.
• Learn what is expected from your department so you can anticipate the needs of the patients, visitors
and employees you service.
• Don’t speak too rapidly – pace rate of speech so you are easily understood.
• Never say: “I don’t know.” Say: “I’ll find out.”
• Never appear hurried even if you are very busy.
• If unable to comply with a patient, visitor or employee’s request, offer them an alternative. Avoid
negative expressions such as: “That’s against company policy.”
• Keep a safe environment for our visitors and ourselves. We’re all members of the PVCHC Safety
Team.
• Keep PVCHC property spotless! If you see something that is out of place, pick it up! Remember, each
of us is a member of the PVCHC Beautification Team.
• Act professionally at all times.
• Take ownership of the patient’s problems, and try to resolve the matter.
• If unable to respond immediately, give a specific time frame in which the patient, visitor or employee
can expect a response.
• Know the services we offer and the locations of all the clinics.
• Go the extra mile!

Click here to mail this form to HR

If you wish to mail your completed application, send to:

Peak Vista Community Health Centers

Attn: Human Resources Dept.
340 Printers Parkway
Colorado Springs, CO 80910

The Mission of Peak Vista Community Health Centers is:

“To provide exceptional healthcare for people facing access barriers”

04.07-150.15