Application for Employment

What type of position are you looking for?
How did you learn about us?
- Advertisement
- Relative
- Friend
- Inquiry
- Employment Agency
- Other
Personal Information
Name*
First Middle Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone number*
Alternate number
Email*
Social Security Number
If you are under 18 years of age, can you provide required proof of your eligibility to work?*
- Yes
- No
Have you ever filed an application with us before?*
- Yes
- No
Have you ever been employed with us before?*
- Yes
- No
Do any of your friends or relatives, other than spouse, work here?*
- Yes
- No
Employee's Name
Are you currently employed?*
- Yes
- No
May we contact your present employer?*
- Yes
- No
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? (Proof of citizenship or immigration status will be required upon employment.)*
- Yes
- No
Date available for work:*
MM slash DD slash YYYY
What is your desired salary range?*
Are you available to work:*
- Full-time
- Part-time
- Temporary
For full-time, please indicate what shift:*
- First
- Second
- Third
For part-time, please indicate:*
- Mornings
- Afternoons
- Evenings
Are you currently on “lay-off” status and subject to recall?*
- Yes
- No
Can you travel if a job requires it?*
- Yes
- No
Education
High School
Name of school:
Address:
Address:
Course of study:
Course of study:
Number of years completed:
Number of years completed:
Degree earned:
Degree earned:
Undergraduate college
Name of school:
Address:
Address:
Course of study:
Course of study:
Number of years completed:
Number of years completed:
Degree earned:
Degree earned:
Graduate/Professional
Name of school:
Address:
Address:
Course of study:
Course of study:
Number of years completed:
Number of years completed:
Degree earned:
Degree earned:
Other (specify)
Name of school:
Address:
Address:
Course of study:
Course of study:
Number of years completed:
Number of years completed:
Degree earned:
Degree earned:
Describe any specialized training, apprenticeship, skills and extracurricular activities.
Describe any job-related training received in the United States military.
Employment Experience
Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected statuses.
1. Employer
Address
Street Address Address Line 2 City State ZIP Code
Phone
Job title
Supervisor
Dates employed
From:
Month
Day
Year
To:
To:
Month
Day
Year
Hourly rate/ salary
Starting:
Final:
Final:
Work performed:
Reason for leaving:
2. Employer
Address
Street Address Address Line 2 City State ZIP Code
Phone
Job title
Supervisor
Dates employed
From:
Month
Day
Year
To:
To:
Month
Day
Year
Hourly rate/ salary
Starting:
Final:
Final:
Work performed:
Reason for leaving:
3. Employer
Address
Street Address Address Line 2 City State ZIP Code
Phone
Job title
Supervisor
Dates employed
From:
Month
Day
Year
To:
To:
Month
Day
Year
Hourly rate/ salary
Starting:
Final:
Final:
Work performed:
Reason for leaving:
4. Employer
Address
Street Address Address Line 2 City State ZIP Code
Phone
Job title
Supervisor
Dates employed
From:
Month
Day
Year
To:
To:
Month
Day
Year
Hourly rate/ salary
Starting:
Final:
Final:
Work performed:
Reason for leaving:
List professional, trade, business or civic activities and offices held.
You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected statuses.
You may also attach a resume as a file here, in addition to fully completing an application
Max. file size: 3 MB.
Additional Information
Other qualifications:
Summarize special job-related skills and qualifications acquired from employment or other experience.
Specialized skills
Check skills/equipment operated:
- Microsoft Office Suite
- EHR
- CPT Coding
WPM
Production/mobile machinery (list):
Other (list):
State any additional information you feel may be helpful to us in considering your application:
Can you perform the essential functions of the job for which you are applying:
- Yes
- No
References
1. Reference Name
Phone
Address
2. Reference Name
Phone
Address
2. Reference Name
Phone
Address
Applicant's Statement
Consent*
I certify that answers given herein are true and complete.

I authorize investigation of all statements contained in this application for employment as may be necessary for arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed in an written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive in this organization.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of this employer.
I agree
Signature of applicant
Date
MM slash DD slash YYYY

Application for Employment

Personal Information

Education

Employment Experience

Additional Information

References

Applicant's Statement