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712-722-1700
877-722-1770

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care@promisechc.org

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33 4th St NW,
Sioux Center, IA

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If you have questions about the application please email Emily Tuschen at: etuschen@promisechc.org.

PERSONAL INFORMATION
What position are you applying for?*
- Bilingual Patient Service Representative
- Dental Hygienist
Do you prefer:*
- Full-Time
- Part-Time
First Name*
Last Name*
Phone*
Street Address*
City, State, Zip*
Your personal email*
How do you prefer to be contacted about this position?*
- Call on my cell phone
- Text on my cell phone
- Email
EDUCATION
Highest level of education completed*
- Middle School
- High School/GED
- College/University
- Graduate School
Name of school/location*
What degree(s) have you earned?*
LICENSURE INFORMATION
Where did you receive your professional training?
Dates of professional training
Place of registration/licensure
License number
License status
- Current
- Expired
EMPLOYMENT HISTORY
Are you currently employed?*
- Yes
- No
Current or Most Recent Employer
Employer Name*
Employer City & State*
Employer Phone*
Title of Position*
Date started employment*
MM slash DD slash YYYY
Date ended employment
MM slash DD slash YYYY
Final Pay*
Supervisor's name/title*
May we contact this employer?*
- Yes
- No
Description of duties, responsibilities and skills used*
Reason for leaving*
Liked most about job*
Liked least about job*
Previous Employer #1
Employer Name*
Employer City & State*
Employer Phone*
Title of Position*
Date started employment*
MM slash DD slash YYYY
Date ended employment
MM slash DD slash YYYY
Final Pay*
Supervisor's name/title*
May we contact this employer?*
- Yes
- No
Description of duties, responsibilities and skills used*
Reason for leaving*
Liked most about job*
Liked least about job*
Previous Employer #2
Employer Name
Employer Phone
Title of Position
Date started employment
MM slash DD slash YYYY
Date ended employment
MM slash DD slash YYYY
Final Pay
Supervisor's name/title
May we contact this employer?
- Yes
- No
Description of duties, responsibilities and skills used
Reason for leaving
Liked most about job
Liked least about job
ADDITIONAL INFORMATION
Indicate any languages, other than English, that you are fluent in for speaking, reading or writing.
What date would you be available to begin your employment with Promise CHC?*
MM slash DD slash YYYY
What schedule do you prefer?*
- Part-Time
- Full-Time
Are you legally eligible to work in the United States of America?*
- Yes
- No
Do you have reliable transportation?*
- Yes
- No
Have you previously worked for Promise CHC?*
- Yes
- No
Do you know anyone at Promise CHC?*
- Yes
- No
If yes, who and what is your relationship to them?
PROFESSIONAL REFERENCES - MUST BE A WORK RELATED REFERENCE
Reference #1 - MUST BE A WORK RELATED/PROFESSIONAL REFERENCE
Full Name*
Phone*
Title*
Company*
Email*
Describe your relationship to this reference*
Reference #2 - MUST BE A WORK RELATED/PROFESSIONAL REFERENCE
Full Name*
Phone*
Title*
Company*
Email*
Describe your relationship to this reference*
Reference #3 - MUST BE A WORK RELATED/PROFESSIONAL REFERENCE
Full Name*
Phone*
Title*
Company*
Email*
Describe your relationship to this reference*
Submit your resume and/or cover letter
Drop files here or
Accepted file types: jpg, pdf, png, Max. file size: 50 MB.
How did you learn about this job opening?*
- Employee Referral (specify below)
- Indeed Advertising
- Facebook
- Instagram
- Tik Tok
- Online job posting/advertising (specify online site below)
- School/College (specify below)
- Poster at a location (specify location below)
Please specify which employee, newspaper, online site, etc., referred you.*
What is your relationship with this person?*
Correct and Complete*
By checking this box and submitting this electronic application, I affirm that all of the information that I have provided in the application is correct and complete to the best of my knowledge.
Promise does not offer tenured or guaranteed employment. Either the employee or company can terminate the employment at any time.
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CONTACT

PROMISE COMMUNITY HEALTH CENTER

33 4th St NW, Sioux Center, IA 51250
Phone: 712-722-1700
Fax: 712-722-1770
Email: care@promisechc.org

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