Kahak Health Care Services is an equal opportunity employer. Kahak Health Care Services does not discriminate because of race, color, religion, national origin, sex, age, marital status, personal appearance, sexual orientation, family responsibility, physical or mental disability, matriculation or political affiliation. PLEASE, PRINT ALL INFORMATION. THIS APPLICATION WILL BE KEPT ACTIVE FOR 60 DAYS ONLY, UNLESS UPDATED BY YOU.
Social Security Number:
Present Address: (Street, City, State, Zip Code):
Mobile Phone #:
Application for: (Select one):
Permanent workPart TimeSummerInternshipTemporaryVolunteer
How were you referred to us? Please specify:
Starting Salary $:
Have you previously applied here?
if so, when?
Are you a U.S. Citizen?
Type of Visa:
Do you have a friend or relative employed by us?
If yes, give Name and Relationship:
Were you ever employed by us?
If yes, From:
Do you have a valid Driver’s License?:
From what state:
License Expires on what date:
Has your driver's license ever been suspended, revoked or put on probation?:
Number of Moving Traffic Violations in the past 3 year?:
Number of traffic accidents over the past 3 years for which you were responsible?:
Have you ever been convicted of driving under the influence of alcohol or drug?:
If yes, state number of times and dates convicted:
Have you ever been convicted of a criminal offense?:
If Yes, state date, place and charge:
Has a civil or criminal complaint ever been filed against you alleging physical or sexual abuse by you?:
If so, state date, place and charge:
Name and Address of School:
Course or Major:
Have you ever terminated your employment or has your employer terminated you for reasons relating to allegations of physical abuse or sexual abuse by you?:
If Yes, explain:
Have you ever received any medical treatment, physical or psychological, for reasons involving physical abuse or sexual abuse by you?:
If Yes, please explain:
List professional societies, organizations, memberships, etc. (Include those which indicate race, color, creed, religion, age, national origin or sex):
Describe briefly what you consider to be your main qualifications for being successful in this job for which you have applied.
Describe briefly any additional skills, knowledge or experience you have which may be of value to a career at the KAHAK HEALTH CARE SERVICES:
Please, list your work experience for the past three years beginning with your most recent job held. If you were self-employed, give firm name.
MOST RECENT FIRST
1. Company Name and complete Address:
Name of Supervisor and Title:
Hourly Pay or Salary:
Employed (Month & Year)::
Job Title and Brief Description of Work:
Reason for Leaving:
2. Company Name and complete Address:
3. Company Name and complete Address:
IN CASE OF EMERGENCY, WHO MAY WE NOTIFY?:
I certify that the above is complete and correct to the best of my knowledge and understanding. I authorize investigation of all information contained in this application for employment. I understand that misrepresentation or omission of facts called for hereon, receipt of unsatisfactory references, or failure to pass the prescribed physical examination or comply all the requirements for employment will be sufficient cause for cancellation of consideration of employment or dismissal from KAHAK HEALTH CARE SERVICES I agree that any ideas, inventions improvements or contracts made or conceived by me during any employment resulting from this application relating to KAHAK HEALTH CARE SERVICES activities or work I perform for KAHAK HEALTH CARE SERVICES shall be the sole property of KAHAK HEALTH CARE SERVICES
Signature of Applicant:
7826 Eastern Ave, N.W. Suite LL14,
Washington D.C 20012