Employment Application

In compliance with applicable laws, the company does not discriminate because of age, sex, race, color, religion, marital status, national origin, veteran status, disability or other applicable protected status.

Instructions:
Be sure to answer all questions. If a question does not apply to you, answer with "no" or "not applicable" (N/A). Do not substitute a resume for the information requested.

Position Preferences
Position Applied For:
Shift Preference:
Status Preference:            
Who referred you to our company?
Minimum salary requirement:
Have you worked for this company before?        
If yes, provide location(s) and dates:
Date you will be available, if offered employment: (MM/DD/YYYY) NOT 'Current' or '2 weeks'
Would you accept employment in another city?        
Preferred Locations:

General Information
Name: First: Middle Initial: Last:
Social Security Number: XXX-XX-XXXX
Address:
City:
State:
Zip / Postal Code:
How long have you lived at this address:
Previous Address:
Previous City:
Previous State:
Previous Zip / Postal Code:
How long did you live at this previous address:
Contact Information  
Home Phone Number: XXX-XXX-XXXX
Work Phone Number: XXX-XXX-XXXX
Mobile Phone Number: XXX-XXX-XXXX
Email Address:
Emergency Contact  
Name:
Phone Number: XXX-XXX-XXXX
Background Information  
United States Citizenship Status:
Visa Number and Expiration, if Applicable:
Armed Forces Experience  
Have you ever served in the U.S. Armed Forces?        
If yes, which branch:
If yes, service start date: (MM/DD/YYYY) NOT 'Current' or '2 weeks'
If yes, service end date: (MM/DD/YYYY) NOT 'Current' or '2 weeks'
Professional Licenses / Registrations  
License / Registration Type(s): List both current and inactive professional licenses and registrations
State:
Number:
Date issued: (MM/DD/YYYY) NOT 'Current' or '2 weeks'
Expiration date: (MM/DD/YYYY) NOT 'Current' or '2 weeks'
Status:
Have you ever received sanctions, been on probation or had limitations on any of your professional licenses or registrations?        
If yes, please explain:
Have you ever been excluded or otherwise made ineligible to participate in any federal programs, including any health care program (e.g. Medicare, Medicaid, etc.) or have you ever been convicted of a criminal offense related to the provision of health care services?        
If yes, please explain:
Have you ever been convicted of a felony:        
If yes, please provide details including offense, date and jurisdiction:
Have you ever been terminated from or asked to resign from a position?        
If yes, name of employer(s):
If yes, when did it happen? (MM/DD/YYYY) NOT 'Current' or '2 weeks'

Employment History
Most Recent  
Name of Employer:
Address:
City:
State:
Zip / Postal Code:
Starting Date: (MM/DD/YYYY) NOT 'Current' or '2 weeks'
Ending Date: (MM/DD/YYYY) NOT 'Current' or '2 weeks'
Positions held:
Starting Salary:
Ending Salary:
Duties, Responsibilities, Number of People Managed:
Why did you leave?
Supervisor Name:
Supervisor Title:
Supervisor Phone Number:
May we contact this Supervisor?        
2nd Most Recent  
Name of Employer:
Address:
City:
State:
Zip / Postal Code:
Starting Date: (MM/DD/YYYY) NOT 'Current' or '2 weeks'
Ending Date: (MM/DD/YYYY) NOT 'Current' or '2 weeks'
Positions held:
Starting Salary:
Ending Salary:
Duties, Responsibilities, Number of People Managed:
Why did you leave?
Supervisor Name:
Supervisor Title:
Supervisor Phone Number:
May we contact this Supervisor?        
3rd Most Recent  
Name of Employer:
Address:
City:
State:
Zip / Postal Code:
Starting Date: (MM/DD/YYYY) NOT 'Current' or '2 weeks'
Ending Date: (MM/DD/YYYY) NOT 'Current' or '2 weeks'
Positions held:
Starting Salary:
Ending Salary:
Duties, Responsibilities, Number of People Managed:
Why did you leave?
Supervisor Name:
Supervisor Title:
Supervisor Phone Number:
May we contact this Supervisor?        
4th Most Recent  
Name of Employer:
Address:
City:
State:
Zip / Postal Code:
Starting Date: (MM/DD/YYYY) NOT 'Current' or '2 weeks'
Ending Date: (MM/DD/YYYY) NOT 'Current' or '2 weeks'
Positions held:
Starting Salary:
Ending Salary:
Duties, Responsibilities, Number of People Managed:
Why did you leave?
Supervisor Name:
Supervisor Title:
Supervisor Phone Number:
May we contact this Supervisor?        
5th Most Recent  
Name of Employer:
Address:
City:
State:
Zip / Postal Code:
Starting Date: (MM/DD/YYYY) NOT 'Current' or '2 weeks'
Ending Date: (MM/DD/YYYY) NOT 'Current' or '2 weeks'
Positions held:
Starting Salary:
Ending Salary:
Duties, Responsibilities, Number of People Managed:
Why did you leave?
Supervisor Name:
Supervisor Title:
Supervisor Phone Number:
May we contact this Supervisor?        
6th Most Recent  
Name of Employer:
Address:
City:
State:
Zip / Postal Code:
Starting Date: (MM/DD/YYYY) NOT 'Current' or '2 weeks'
Ending Date: (MM/DD/YYYY) NOT 'Current' or '2 weeks'
Positions held:
Starting Salary:
Ending Salary:
Duties, Responsibilities, Number of People Managed:
Why did you leave?
Supervisor Name:
Supervisor Title:
Supervisor Phone Number:
May we contact this Supervisor?        

Education History
High School / G.E.D.  
Name of Institution:
Highest Grade Completed:
Grade Point Average:
Graduated:            
If yes, what was your degree and major?
Extracurricular activities, awards, academic honors, etc.
College  
Name of Institution:
Highest Grade Completed:
Grade Point Average:
Graduated:            
If yes, what was your degree and major?
Extracurricular activities, awards, academic honors, etc.
Starting Date: (MM/DD/YYYY) NOT 'Current' or '2 weeks'
Ending Date: (MM/DD/YYYY) NOT 'Current' or '2 weeks'
2nd College  
Name of Institution:
Highest Grade Completed:
Grade Point Average:
Graduated:            
If yes, what was your degree and major?
Extracurricular activities, awards, academic honors, etc.
Starting Date: (MM/DD/YYYY) NOT 'Current' or '2 weeks'
Ending Date: (MM/DD/YYYY) NOT 'Current' or '2 weeks'
Graduate School  
Name of Institution:
Highest Grade Completed:
Grade Point Average:
Graduated:            
If yes, what was your degree and major?
Extracurricular activities, awards, academic honors, etc.
Starting Date: (MM/DD/YYYY) NOT 'Current' or '2 weeks'
Ending Date: (MM/DD/YYYY) NOT 'Current' or '2 weeks'
Other Institution  
Name of Institution:
Highest Grade Completed:
Grade Point Average:
Graduated:            
If yes, what was your degree and major?
Extracurricular activities, awards, academic honors, etc.
Starting Date: (MM/DD/YYYY) NOT 'Current' or '2 weeks'
Ending Date: (MM/DD/YYYY) NOT 'Current' or '2 weeks'

Activities
Current or past membership in civic, professional or other organizations of which you would like us to be aware:
Hobbies and other interests:

Skill Summary
  Years Type of Work / Name of Software
Accounting:
Billing:
Medical Records:
Calculator:
Typing: Words per minute
Data Entry:
Word Processing:
Spreadsheets:
Databases:
Other Software:
Other Software:
In compliance with applicable laws, the company does not discriminate because of age, sex, race, color, religion, marital status, national origin, veteran status, disability or other applicable protected status.