Dental Referral/Insurance Coordinator at Yakutat Community Health Center

First Name *

Last Name *

Middle Initial

Street Address *

Apartment/Unit #

City *

State *

Zip Code *

Email *

Phone *

If you do not currently live in Yakutat, Alaska have you researched the community and environment, and are you willing to relocate to this wonderful community in rural Alaska? *

Date Available *

Desired Salary *

Type of Position Interested In *

Full-Time
Part-Time
On-Call/Intermittent
Other

Are you 18 years of age or older? *

Do you have a valid driver's license? *

Native Preference Candidate *

Copy of Tribal Enrollment Certificate and/or Bureau of Indian Affairs Certificate of Indian Blood

Highest Level of Education Completed *

Are you a citizen of the United States? *

If you are not a US citizen, are you legally authorized to work in the United States? *

Have you ever worked for the Yakutat Community Health Center (YCHC)? *

If you have worked for YCHC, provide dates of employment and position.

Have you ever been convicted of or pled no contest to a misdemeanor? *

If you have been convicted of or pled no contest to a misdemeanor explain and provide dates of conviction?

Have you ever been convicted of or pled no contest to a felony? *

If you have been convicted of or pled no contest to a felony explain and provide dates of conviction?

Have you ever been involuntarily terminated from employment? *

If you have been involuntarily terminated, please explain.

High School Name *

High School Address (City/State) *

High School Start Date

High School End Date

Did you Graduate? *

College Name

College Address (City/State)

Dates Attended College

College Major/Couse of Study

College - Did you graduate?

College Degree

Other Educational Institution Address (City/State)

Other Educational Institution Name

Other Educational Institution Dates Attended

Other Education - Did you graduate?

Other Educational Degree

Please Upload a Current Resume (Optional)

Please describe your specific experience related to that required for the position, including employer, job title, relevant duties and dates of employment. *

Please select the computer systems and software applications you have worked with and are proficient in. *

Please explain why you are interested in the position you applied for and why you would like to work for the Yakutat Community Health Center. *

Professional Reference #1 Name *

Professional Reference #1 Relationship *

Professional Reference #1 Company

Professional Reference #1 Job Title

Professional Reference #1 Phone Number *

Professional Reference #1 Email Address *

Professional Reference #2 Name *

Professional Reference #2 Relationship *

Professional Reference #2 Company

Professional Reference #2 Job Title

Professional Reference #2 Phone Number *

Professional Reference #2 Email Address *

Professional Reference #3 Name *

Professional Reference #3 Relationship *

Professional Reference #3 Company

Professional Reference #3 Job Title

Professional Reference #3 Phone Number *

Professional Reference #3 Email Address *

Previous Employer (1) Name *

Previous Employer (1) Phone Number *

Previous Employer (1) Employer Address *

Previous Employer (1) Supervisor Name *

Previous Employer (1) Job Title *

Previous Employer (1) Job Duties/Responsibilities *

Previous Employer (1) Starting Salary *

Previous Employer (1) Ending Salary *

Previous Employer (1) Employment Start Date *

Previous Employer (1) Employment End Date *

Previous Employer (1) Reason For Leaving *

May we contact this current/most recent employer? *

Previous Employer (2) Name

Previous Employer (2) Phone Number

Previous Employer (2) Address

Previous Employer (2) Supervisor Name

Previous Employer (2) Job Title

Previous Employer (2) Job Duties/Responsibilities

Previous Employer (2) Starting Salary

Previous Employer (2) Ending Salary

Previous Employer (2) Employment Start Date

Previous Employer (2) Employment End Date

Previous Employer (2) Reason For Leaving

May we contact this previous employer(2)?

Previous Employer (3) Name

Previous Employer (3) Phone Number

Previous Employer (3) Address

Previous Employer (3) Supervisor Name

Previous Employer (3) Job Title

Previous Employer (3) Job Duties/Responsibilities

Previous Employer (3) Starting Salary

Previous Employer (3) Ending Salary

Previous Employer (3) Employment Start Date

Previous Employer (3) Employment End Date

Previous Employer (3) Reason For Leaving

May we contact this previous employer (3)?

Military Service *

Branch of Service

Military Service Start Date

Military Service End Date

Rank at Discharge

Type of Discharge

Explanation if Other Than Honorable

I understand all employment at the Yakutat Tlingit Tribe/Yakutat Community Health Center is “at will”. This means that the employee or Yakutat Tlingit Tribe/Yakutat Community Health Center may terminate employment at any time and for any reason. Unless specified in writing, no term of employment is expressed or implied for this position. *

Yes

I have carefully read the minimum qualifications for this position, and certifying that I possess the required education and/or experience to meet the minimum qualification as stated? *

I understand Yakutat Tlingit Tribe/Yakutat Community Health Center is a drug free workplace. Employees must pass a pre-employment (receive negative test result) and random drug and alcohol screening to be eligible for and to maintain employment. *

Yes

I understand the Yakutat Tlingit Tribe/Yakutat Community Health Center requires a criminal background check. All employment offers are conditional until Yakutat Tlingit Tribe/Yakutat Community Health Center has completed a criminal background check and verified eligibility for employment. *

Yes

I certify that I have read this application carefully and that my answers are true and complete to the best of my knowledge. *

Yes

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my immediate release. *

Yes

See all the jobs at Yakutat Community Health Center here: http://ychc.recruiterbox.com/jobs

Application Form