Mission City Community Network, Inc.

An Equal Opportunity Employer

Employment Application
An

Sites:

Inglewood

Hollywood

Mission Hills

Monrovia

North Hills Northridge

Pacoima

Pomona

Other____________

MCCN is a Drug Free Work place Pre placement Drug Screens Required.
Please Print
Date:
Cirne

Dialys

Aileen

Last Name

First Name

Middle

Present Address

Mailing Address (if different from present address)

8814 s Vermont Ave

Number & Street

Los Angeles
City

Number & Street

CA

90044
_

State

Zip

323

(_____) 7073922
Cell Phone

_____

_
City

State

323 22449795
(_____)
Home Phone

Zip

dialyscirne@gmail.com
____________

_____

Email Address

EMPLOYMENT DESIRED
Position applying for: Medical Assistant

$ 14.00

Salary desired:

Must Enter Dollar Figure

Are you applying for:

Regular full-time work?..

Yes
Yes
Regular part-time work? ..

Temporary work, e.g., summer or holiday work?

Yes

No
No
No

What days and hours are you not available for work?

n/a

___

If applying for temporary work, during what period of time will you be available?

0.00
0.00
From:_______
To:_______

Are you available for work on weekends? ..

Yes

Would you be available to work overtime, if necessary? .

Yes

No

No

2014
18
12
If hired, on what date can you start work? . _____/_____/_____
PERSONAL INFORMATION
How were you referred to Mission City Comunity Network, Inc.?
Walk-in
Craigslist

MCCN Website
Family/Friend
Other ____________________________

School/University _____________________________
Name of School/University

Have you ever applied to or worked for Mission City Community Network, Inc. before? .
If yes, when? n/a

Yes

No

Do you have any friends or relatives working for Mission City Community Network, Inc.?

Yes

No

If yes, state name(s) and relationship:

n/a

n/a

Name

Relationship

n/a

n/a

Name

Relationship

Why are you applying for work at Mission City Community Network, Inc.?

It would help my career.

Rev. 10.12

Mission City Community Network, Inc. - Employment Application - Page 2

If hired, would you have a reliable means of transportation to and from work? ...
Yes

No

Are you at least 18 years old?(If under 18, hire subject to verification that

you are of minimum legal age.) ...

Yes No
If hired, can you present evidence of your U.S. citizenship or

proof of your legal right to live and work in this country?

Yes No
Are you able to perform the essential functions of the job for which you are applying,

either with or without reasonable accommodation? ....

Yes
If no, describe the functions that cannot be preformed.

No

n/a
N/A
(Note: We comply with the ADA and consider reasonable accommodation measures that may be necessary for
eligible applicants/employees to perform essential functions. Hire may be subject to passing a medical examination,
and to skill and agility tests.)

Have you ever been convicted of a criminal offense (felony or misdemeanor)?

Yes
No
If yes, state nature of the crime(s), when and where convicted and disposition of the case.

N/A

N/A
N/A
(Note: No Applicant will be denied employment solely on the grounds of conviction of a criminal offense. The nature
of the offense, the date of the offense, the surrounding circumstances and the relevance of the offense to the
position(s) applied for may, however, be considered.)

Are you currently employed? .... Yes

No

If so, may we contact your current employer? ..

No

Yes

EDUCATION, TRAINING AND EXPERIENCE

School Name
And Address

No. of years
Completed

Los Angeles Highschool

School 4650 W. Olympic Blvd

High

Address

College/ Elac
University 1301 Avenida Cesar Chavez
Address

Vocational/ American Career College

Business 151 Innovation Drive
Address

Did you
Graduate?

Yes

Degree
Or Diploma
No

Diploma

Los Angeles

CA

90019

City

State

Zip

Yes

No

n/a

Monterey Park

CA

91754

City

State

Zip

9months

Irvine

CA

Diploma
92617

City

State

Zip

Health n/a

Yes

Yes

No

No

Care
Address

City

State

Zip

Many of our customers (clients) do not speak English. Do you speak, write or

understand any foreign languages?

Yes
If yes, which languages(s)? Spanol

Rev. 10.12

No

Mission City Community Network, Inc. - Employment Application - Page 3

Do you have any other experience, training, qualifications or skills which you feel make you

Especially suited for work at Mission City Community Network, Inc.? .

Yes

No

If so, please explain:

Passion to share what I've picked through out my career as a medical assistant.

Answer the following questions if you are applying for a professional position:

Are you licensed/certified for the job applied? .

Yes

No

Name of license/certification:
Issuing State:

License/certification Number:

Has your license/certification ever been revoked or suspended? . Yes

No

If yes, state reason(s), date of revocation or suspension and date of reinstatement.

EMPLOYMENT HISTORY
List below all present ad past employment starting with your most recent employer (last five years is sufficient).
Account for all periods of unemployment. You must complete this section even if attaching a resume.

Airport Medical

( 310 ) 2153355

03 15 2013to ___/___/___
07 1 2014
___/___/____

Name of Employer

Telephone No.

Dates of Employment

Health care

Jose Gomez

12.00

13.00

Type of Business

Your Supervisors Name

Hourly Pay Starting

Ending

1117 W Manchester Blvd Ste I

Inglewood

CA

90301

Address

City

State

Zip

Medical Assistant front and back office.

Your Position and Duties

Relocated.
Reason for Leaving?

May we contact this employer for a reference? ..

Yes

No

Allied Medical

( 213 ) 4279869

11 8 2012to ___/___/___
01 20 2013
___/___/____

Name of Employer

Telephone No.

Dates of Employment

Medical Practice

Freddy Campos

13.00

13.50

Type of Business

Your Supervisors Name

Hourly Pay Starting

Ending

3240 Wilshire Blvd Ste 240

Los Angeles

CA

90010

Address

City

State

Zip

Medical Assistant Front and back office.

Your Position and Duties

Layoff.
Reason for Leaving?

May we contact this employer for a reference? .. Yes

Rev. 10.12

No

Mission City Community Network, Inc. - Employment Application - Page 4

EMPLOYMENT HISTORY, Continued
(
Name of Employer

Type of Business

Telephone No.

Your Supervisors Name

Address

City

___/___/____ to ___/___/___
Dates of Employment

Hourly Pay Starting

Ending

State

Zip

Your Position and Duties

Reason for Leaving?

May we contact this employer for a reference? .. Yes

(
Name of Employer

Type of Business

Telephone No.

Your Supervisors Name

Address

City

No

___/___/____ to ___/___/___
Dates of Employment

Hourly Pay Starting

Ending

State

Zip

Your Position and Duties

Reason for Leaving?

May we contact this employer for a reference? .. Yes

(
Name of Employer

Type of Business

Telephone No.

Your Supervisors Name

Address

City

No

___/___/____ to ___/___/___
Dates of Employment

Hourly Pay Starting

State

Ending
Zip

Your Position and Duties

Reason for Leaving?

May we contact this employer for a reference? .. Yes

No

Note: Attach additional page(s) if necessary.

MILITARY SERVICE
Have you obtained any special skills or abilities as the result of service in the military? Yes
If so, describe:

Rev. 10.12

No

Mission City Community Network, Inc. - Employment Application - Page 5

REFERENCES
List below three persons not related to you who have knowledge of your work performance within the last
three years.

Medical Assistant
________________________

n/a
_______________

Name

Occupation

Company

co-worker
_______________________________

2139486319
________________________

9
_______________

Relationship

Phone #

No. years acquainted

office clerk
________________________

n/a
_______________

Name

Occupation

Company

__________________________________
Relationship

co-worker

___________________________
Phone #

3232534447

_________________
No. years acquainted

Cristian Martinez
3. _______________________________

________________________

Designer

n/a
_______________

Occupation

Company

3237910228

_________________
No. years acquainted

Monseratt Diaz
1. _______________________________

Emma Arguello
2. _______________________________

Name

co-worker

__________________________________
Relationship

___________________________
Phone #

13

20

PLEASE READ CAREFULLY, INITIAL EACH PARAGRAPH AND SIGN BELOW.

DC
Initials

DC
Initials

DC
Initials

I hereby certify that I have not knowingly withheld any information that might adversely
affect my chances for employment and that the answers given by me re true and correct to
the best of my knowledge. I further certify that I, the undersigned applicant, have personally
completed this application. I understand that any omission or misstatement of material fact
in this application or on any document used to secure employment shall be grounds for
rejection of this application or for immediate discharge if I am employed, regardless of the
time elapsed before discovery.
I hereby authorize Mission City Community Network, Inc. to thoroughly investigate my
references, work record, education and matters related to my suitability for employment and,
further, authorize the references I have listed to disclose to the company any and all letters,
reports and other information related to my work records, without giving me prior notice of
such disclosure. In addition, I hereby release Mission City Community Network, Inc., my
former employers and all other persons, corporation, partnerships, and associations from any
and all claims, demands, or liabilities arising out of or in any way related to such
investigations or disclosure.
I understand that nothing contained in the application, or conveyed during any interview
which may be grated or during my employment, if hires, is intended to create an employment
contract between me and Mission City Community Network, Inc. In addition, I understand
and agree that if I am employed, my employment is for no definite or determinable period
and may be terminated at any time, with or without prior notice, at the option of either
myself or the company, and that no promises or representations contrary to the foregoing are
binding on Mission City Community Network, Inc. unless made in writing and signed by me
and the companys designated representative,

DC
Date

Rev. 10.12

Applicants Signature

Consent to Check References Form

Mission City Community Network, Inc. will check references before hiring. To do this we may contact
persons whose names you have supplied. In addition, we may also speak with friends, ex co-workers,
business associates and others. We may ask questions that touch on your personal background, your
education, your work performance, your personality and your character.
Listed below are the standard questions that are asked of previous and present employers.

Dialys Cirne
I, ___________________________________
have read and fully understand the above. I give permission
to __________________________________________ or any persons designated by Mission City
Community Network, Inc. to check my references as described above, including the asking of any questions
about my personal background, my education, my work performance, my personality and character. As
well as the completion of the previous/present employment verification questions.
____________________________________________
Applicants Signature

12/18/14
___________________________
Date

Dialys Cirne
_____________________________________________
Print Name
APPLICANT DO NOT WRITE BELOW THIS LINE
PREVIOUS OR CURRENT EMPLOYMENT VERIFICATION
Company Name: _____________________________________________________________________
Employees Name: ____________________________________________________________________
Dates of Employment:

Start Date: _______________

End Date: _______________

Rate of Pay:

Starting Rate: _____________

Ending Rate: ______________

Position Held: ________________________________

Attendance:

Excellent

Good

Poor

No Comment

Other: ___________

Productivity:

Excellent

Good

Poor

No Comment

Other: ___________

Job Knowledge:

Excellent

Good

Poor

No Comment

Other: ___________

Adherence to Policy: Excellent

Good

Poor

No Comment

Other: ___________

Patient/Staff
Relationship:

Excellent

Good

Poor

No Comment

Other: ___________

Work Performance:

Excellent

Good

Poor

No Comment

Other: ___________

Comments:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Completed By:
Print Name: __________________________________________

Date: ______________________

Signature: ___________________________________________

Title: _______________________

Rev. 10.12