New Mexico's Health Quality Improvement Organization

Job Application Form

Federal, state, and local laws prohibit discrimination in employment because of gender, age, race, color, religious creed, citizenship, marital status, national origin, ancestry, military status or disability.

PERSONAL

Name:
	First	Middle	Last
Address:
	Street

	City	State	Zip

Previous Street Address:
(If less than five years at present address)

Work Phone Number:

Home Phone Number:

If you are under 18 years of age, do you have a valid work permit?

Yes

How were you referred to NMMRA?

Agency

Employee

Other

Have you ever been employed by NMMRA? Yes No

If so, please state when and by what name (if different from above)

To be considered "qualified" under the American with Disabilities Act, an applicant must be able to perform the essential functions of a job with or without a reasonable accommodation. Please review the essential functions listed in the job advertisement and answer the following question: "Can you perform the essential functions of the position for which you applied with or without a reasonable accommodation, by NMMRA?"

Yes

If you answered "no," please identify what essential job functions you cannot perform with or without a reasonable accommodation by NMMRA:

Are you either a citizen of the United States or a legal alien who has the right to work in the United States? (You will be required to produce proof of your right to work following a conditional offer of employment.)

Yes

Have you ever been convicted of a crime other than a minor traffic violation? (Conviction will not be an automatic ban to employment.) If the answer is 'Yes,' NMMRA may require additional information.

Yes

EMPLOYMENT OBJECTIVES

Position desired:

Approximate salary expected:

Date available to start work:

EMPLOYMENT HISTORY

Present or Current Employer

Employer:		Position:
Address:		City, State, Zip:

Supervisor's Name and Title:
	Phone Number: Ext.:
Dates Employed:	From:	To:
Base Salary or Wage:	Start:	End:
Nature of Duties:
Reason for Leaving:

Permission to Contact Present Employer to Check References:

Yes

Previous Employer

Employer:		Position:
Address:		City, State, Zip:

Supervisor's Name and Title:
	Phone Number: Ext.:
Dates Employed:	From:	To:
Base Salary or Wage:	Start:	End:
Nature of Duties:
Reason for Leaving:

Permission to Contact Present Employer to Check References:

Yes

Additional Previous Employers

Employment Dates From: To:	Company and Address	Title or type of Work	Base Salary	Reason for Leaving

Please account for any break in employment over 30 days

EDUCATION

School Attended	Name	City, State, Zip	Highest Level Completed	Course of Study - Major	Degree
High School
College
Graduate School
Business or Trade School

List any business skills, software and computer knowledge or special training you have:

Indicate your professional designation(s) or other certification(s), if any:

I hereby authorize any organization affiliated with NMMRA to make any inquiry into my background deemed necessary. I further authorize all persons, schools, companies, corporations, employers or former employers, and law enforcement agencies to supply all information concerning my background and to furnish reports thereon, and I hereby release NMMRA and any organization affiliated with NMMRA from any and all liability and responsibility. I understand that inquiries may be made of any references that I provide.

I agree to conform to the rules and regulations of the company. My employment may be terminated at any time at the option of either the company or myself. I understand that only the Chief Executive Officer in writing has authority to enter into any other agreement for employment for any specific period of time or make any agreement contrary to the foregoing.

I certify that the answers given to me by all the questions on this application and any attachments are, to the best of my knowledge and belief, true and accurate and that I have not withheld any pertinent facts or circumstances. I understand that my omission or misrepresentation of fact in this application may result in refusal of/or termination of employment upon discovery thereof.

Enter Value: