Joseph P. Addabbo Family Health Centers

E-ADDABBO

Applicant Information

Last Name

First Name

Date

Street Address

Aparment/Unit #

City

State

Zip Code

Phone	E-mail Address
Date Available	Desired Wage

Position Applied For

Are you a citizen of the United States? Yes No	If no, are you authorized to work in the US? Yes No
Have you ever worked for this company? Yes No	If so, when?
Have you ever been convicted of a felony? Yes No	If so, when?

Type of Employment Desired (Check all that apply)
Seasonal Temporary Full-Time Part-Time Shift Work

Other

Employee Experience

Please list three professional references

Full Name	Relationship
Company	Phone Number

Address:

Full Name	Relationship
Company	Phone Number

Address:

Full Name	Relationship
Company	Phone Number

Address:

Military Service

Branch	Dates
Rank at Discharge	Type of Discharge

If other than honorable, please explain.

Education: Check the Number of years completed

Highschool
1 2 3 4

College
1 2 3 4

Graduate Degree
1 2 3 4

Technical School
1 2 3 4

Describe your major area of study

List any other considerations for the type of employment you are seeking:

By submitting the answers and sending them you certify that the answers are true to the best of your knowledge.
All potential employees are evaluated without regard to race, color, religion, sex national origin, age, disability, veteran status or other legally protected status.

Image of clinic at 6200 Rockaway Boulevard

Image of clinic at 114-39 Stutphin Avenue