Connected Communities Health Careers Job Fair Application

If you have any questions about the form or the Health Careers Job Fair please contact Maya Crane at admin@connectedcommunitiesroc.org or 585-224-1083

Name (First & Last) *
Name (First & Last)
Address *
Address
Please indicate when you would be available to start if hired.
Positions Applying For *
Please indicate which positions you are interested in applying for by checking all that apply.
A conviction will not bar you necessarily from becoming employed. Employers do reserve the right to conduct a background check of all potential employees.
Please indicate the following information: 1) School Name ; 2) Address of School ; 3) Years You Attended School ; 4) If you graduated ; 5) Type of Degree
Please indicate the following information: 1) School Name ; 2) Address of School ; 3) Years You Attended School ; 4) If you graduated ; 5) Type of Degree
Please indicate the following information: 1) School Name ; 2) Address of School ; 3) Years You Attended School ; 4) If you graduated ; 5) Type of Degree
Please indicate the following in the space below: 1) Company Name ; 2) Full Street Address ; 3) Supervisor's First & Last Name ; 4) Phone Number ; 5) May we contact them? ; 6) Your responsibilities while working here
Please indicate the following in the space below: 1) Company Name ; 2) Full Street Address ; 3) Supervisor's First & Last Name ; 4) Phone Number ; 5) May we contact them? ; 6) Your responsibilities while working here
Please indicate the following in the space below: 1) Company Name ; 2) Full Street Address ; 3) Supervisor's First & Last Name ; 4) Phone Number ; 5) May we contact them? ; 6) Your responsibilities while working here
Please indicate the following in the space below: 1) Full Name ; 2) Full Street Address ; 3) Phone Number ; 4) Relationship To You
Please indicate the following in the space below: 1) Full Name ; 2) Full Street Address ; 3) Phone Number ; 4) Relationship To You
Please indicate the following in the space below: 1) Full Name ; 2) Full Street Address ; 3) Phone Number ; 4) Relationship To You
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 any person, organization or company listed on this application to furnish you any and all information concerning my previous employment, education and qualifications for employment. I also authorize you to re- quest and receive such information. In consideration for my employment, I agree to abide by the rules and regulations of the company, which rules may be changed, withdrawn, added or interpreted at any time, at the company’s sole option and without prior notice to me. I also acknowledge that my employment may be terminated, or any offer or acceptance of employment with- drawn, at any time, with or without cause, and with or without prior notice at the option of the company or myself. I understand that typing my full name in the space below serves as an electronic signature.