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Location
1234 Community street
Orem, Utah 84057
Near community center
Phone
Main: (555) 123-CARE
Emergency Line: (555) 123-9911
Pharmacy: 123-MEDS
Hours
Monday - Friday 10:00 AM - 6:00 PM
Saturday - Sunday Closed
*For Emergencies call 911*
info@binghamfamilyclinic.org
appointments@binghamfamilyclinic.org
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Personal Information
Full Name:
Date of Birth:
Address:
Email:
Phone:
Language Skills:
Position Information
Shift Availability:
Preferred Shift:
Time Commitment:
Start Date Availability
Educational Background (indicate in progress)
Year
Institution
Degree or Certification
2020
University Name
Bachelor of Science
2020
University Name
Bachelor of Science
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Skills (list in order of proficiency and 1-5, 5 indicating expert)
*If you are certified, licensed or credentialed list those skills first.
Skill 1
Skill 2
Skill 3
Skill 4
Skill 5
Skill 6
Skill 7
Skill 8
Letters of Recommendation:
Recommendation letters should be emailed to info@binghamfamilyclinic.org with applicant's name included in the subject line.
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Contact Information
Attachments:
Resume/CV Attachment
Cover Letter Attachment
Government ID
Request Packet for Medical Licensure or Certification
For credentialed providers contact: credentialing@binghamfamilyclinic.org
Declaration:
By submitting this application, I confirm that the information provided is accurate, and I understand that any false statements may disqualify me from volunteer service.
I agree to complete and pay for a background check by following the link that will be provided to me after signature a review of the application.
Signature
Type your full name
Date
Submit Application
info@binghamfamilyclinic.org
www.binghamfamilyclinic.org
Personal Information
Full Name:
Date of Birth:
Address:
Email:
Phone:
Language Skills:
Position Information
Shift Availability:
Preferred Shift:
Time Commitment:
Start Date Availability
Educational Background (indicate in progress)
Year
Institution
2020
University Name
Bachelor of Science
2020
University Name
Bachelor of Science
Add Row
Skills (list in order of proficiency and 1-5, 5 indicating expert)
*If you are certified, licensed or credentialed list those skills first.
Skill 1
Skill 2
Skill 3
Skill 4
Skill 5
Skill 6
Skill 7
Skill 8
Letters of Recommendation:
Recommendation letters should be emailed to info@binghamfamilyclinic.org with applicant's name included in the subject line.
Name
Contact Information
Name
Contact Information
Attachments:
Resume/CV Attachment
Cover Letter Attachment
Government ID
Request Packet for Medical Licensure or Certification
For credentialed providers contact: credentialing@binghamfamilyclinic.org
Declaration:
By submitting this application, I confirm that the information provided is accurate, and I understand that any false statements may disqualify me from volunteer service.
I agree to complete and pay for a background check by following the link that will be provided to me after signature a review of the application.
Signature
Type your full name
Date
Submit Application
info@binghamfamilyclinic.org
www.binghamfamilyclinic.org
Personal Information
Full Name:
Date of Birth:
Address:
Email:
Phone:
Language Skills:
Position Information
Shift Availability:
Preferred Shift:
Time Commitment:
Start Date Availability
Educational Background (indicate in progress)
Year
Institution
Degree or Certification
2020
University Name
Bachelor of Science
2020
University Name
Bachelor of Science
Add Row
Skills (list in order of proficiency and 1-5, 5 indicating expert)
*If you are certified, licensed or credentialed list those skills first.
Skill 1
Skill 2
Skill 3
Skill 4
Skill 5
Skill 6
Skill 7
Skill 8
Letters of Recommendation:
Recommendation letters should be emailed to info@binghamfamilyclinic.org with applicant's name included in the subject line.
Name
Contact Information
Name
Contact Information
Attachments:
Resume/CV Attachment
Cover Letter Attachment
Government ID
Request Packet for Medical Licensure or Certification
For credentialed providers contact: credentialing@binghamfamilyclinic.org
Declaration:
By submitting this application, I confirm that the information provided is accurate, and I understand that any false statements may disqualify me from volunteer service.
I agree to complete and pay for a background check by following the link that will be provided to me after signature a review of the application.
Signature
Type your full name
Date
Submit Application
info@binghamfamilyclinic.org
www.binghamfamilyclinic.org