La Clinica de Familia Application for Employment

Employment Desired*
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Applicant Contact Info

General Info


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Skills and Qualifications

Employment Experience

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Other Experience and Training

By Submitting this Form, You Agree to the Following:

Please read each section carefully. Check the box following each section to confirm you have read and understand each statement. Type your full name when requested, this will be taken as your digital signature.

General Disclaimer

I certify that answers 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 any employment decision.

This application for employment shall be considered active for as long as the position for which the applicant has applied is open. 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 an authorized executive of this organization specifically acknowledges such change in writing.

I understand that false or misleading information given in my application or interview(s) may result in my not being hired, or discharged in the event of employment. I understand also, that I am required to abide by all rules and regulations of the employer.

Employer Immunity From Liability for Reference on Former Employee

When requested to provide a reference on a former or current employee, an employer acting in good faith is immune from liability for communicating about the former employee's performance. The immunity shall not apply when the reference information supplied was knowingly false or deliberately misleading, was rendered with malicious purpose or violated any civil rights of the former employee. (NM statutes, amended 1978, chapter 50, article12, section 1).

I have read and understand the above statements. I authorize my current and former employer to release information about job performance during my tenure of employment to an agent of La Clinica de Familia.

Consent for Drug Testing

I do hereby agree to submit to testing for detection of drugs and alcohol. I give permission for test results to be released to La Clinica de Familia, Inc. I understand that, positive results, refusal to be tested, or any attempt to affect test results or test sample will result in withdrawal of my application for employment, withdrawal of any provisional employment offer I received from La Clinica de Familia or termination of employment, depending on when results are received.


Motor Vehicle Driving Records

Your driving record is an important part of your employment application. Employment is contingent upon verification of a good driving record as applicable to the job requirements. You must secure a Motor Vehicle Driving Record as part of the employment process. All information concerning your driving record, and other information set forth in your application, will be verified. False information will result in discharge from employment or termination of the employment application process.

Final Confirmation

Please type your full name in to the section below. By doing so, you indicate you have read, understand, and verified each statement above.