First Name*
Last Name*
Email Address*
Phone*
Who referred you to this position? Enter their first and last name here.
What's your citizenship / employment eligibility?*
No answer I am a U.S. Citizen/Permanent Resident Non-citizen allowed to work for any employer Non-citizen allowed to work for current employer Non-citizen seeking work authorization I am a Canadian Citizen/Permanent Resident Other
What's your highest level of education completed?
No answer GED or Equivalent High School Some College College - Associates College - Bachelor of Arts College - Bachelor of Fine Arts College - Bachelor of Science College - Master of Arts College - Master of Science College - Master of Fine Arts College - Master of Business Administration College - Doctorate Medical Doctor Other
College or University*
Are you 18 years of age or older?*
No answer Yes No
What languages do you speak fluently?
Desired salary
Earliest start date?*
Have you ever been convicted of a felony?
No answer No Yes
If “Yes”, you have been convicted of a felony, please explain the circumstances around the conviction:
References: Please enter names and contact information:
Have you ever been employed with Lower Lights Christian Health Center?*
-- No answer -- Yes No
If yes, when were you previously employed?
Minimum Acceptable Hourly/Salary Expectation? (REQUIRED for further consideration)*
Select if minimum acceptable wage stated is hourly or salary.*
-- No answer -- Hourly Salary
List up to 4 references - Name, Email and Phone*
Have you received COVID vaccination?*
-- No answer -- Yes No
If not vaccinated are you willing to take the COVID vaccine, upon hire?*
-- No answer -- Yes No I have an exemption
Are you related to any LLCHC Board Member by blood, adoption or marriage?*
If yes, which Board Member
Are you bilingual? If so, please note bilingual language abilities and proficiency (i.e., fluent, moderate, read/write only, etc..) If none, please answer with an "N/A."*
Invitation for Job Applicants to Self-Identify as a U.S. Veteran
A “disabled veteran” is one of the following:
a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or
a person who was discharged or released from active duty because of a service-connected disability.
A “recently separated veteran” means any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service.
An “active duty wartime or campaign badge veteran” means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.
An “Armed forces service medal veteran” means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.
Voluntary Self-Identification of Disability
Voluntary Self-Identification of Disability Form CC-305
Why are you being asked to complete this form?
How do you know if you have a disability?