Policy, Billing, Claim Status

Application for Employment

We consider applications without regard to race, color, religion, creed, sex, national origin, disability, sexual orientation, citizenship status or any other legally protected status.

Basic Information

Position(s) Applied For

Date of Application

Enter today's date in the following format: dd/mm/yyyy

How did you learn about us?

Friend

Employment Agency

Relative

Inquiry

Other

First Name

Last Name

Street Address 1

City

Apartment Number

State

Enter a 2 digit state abbreviation

Zip

Email Address

Telephone Number

Enter a phone number in the following format: 000-000-0000

Background Survey

If you are under 18 years of age, can you provide required proof of your eligibility to work?

Yes

Best Time to Contact You

Example: 8:00am - 4:00pm

Have you ever filed an application with us before?

Yes

If Yes, give date:

If yes, enter the date in the following format: dd/mm/yyyy

Have you ever been employed with us before?

Yes

If Yes, give date:

If yes, enter the date in the following format: dd/mm/yyyy

May we contact your present employer?

Yes

Are you currently employed?

Yes

Do any of your friends or relatives, other than spouse, work here?

Yes

What is your desired salary range?

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

Date Available for Work:

Enter the date in the following format: dd/mm/yyyy

Are you available to work:

Full Time

Part Time

Are you currently on "lay-off" status and subject to recall?

Yes

Can you travel if a job requires it?

Yes

Have you been convicted of a felony within the last five years?

Yes

Education

Select the Highest Level of Completed Education

Name of School

School Address

Course of Study

Number of Years Completed

Diploma Degree

Describe any specialized training, apprenticeship, skills and extra-curricular activities:

Specialized training, apprenticeship, skills and extra-curricular activities

Enter the name of your specialized skill, training, apprenticeship and any other extra-curricular activities

Date Completed

Enter the date in the following format: dd/mm/yyyy

Describe the specialized training, apprenticeship, skills and extra-curricular activities in detail.

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 status.

Employer

Job Title

Address

Enter the address, city, state and zip code

Telephone Number

Enter a phone number in the following format: 000-000-0000

Dates Employed

mm/yy - mm/yy

Houry Rates/Salary

Supervisor

Reason for Leaving

Work Performed

Employer

Job Title

Address

Enter the address, city, state and zip code

Telephone Number

Enter a phone number in the following format: 000-000-0000

Dates Employed

mm/yy - mm/yy

Hourly Rates/Salary

Supervisor

Reason for Leaving

Work Performed

List professional, trade, business or civic activities and offices held.

You may exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability or other protected status.

Additional Information

Other Qualifications

Specialized Skills

Terminal

Spreadsheet

PC/Mac

Word Processing

Typewriter

Shorthand

Typewriter Words Per Minute

Shorthand Words Per Minute

Production/Mobile Machinery (List)

Other (List)

State any additional information you feel may be helpful to us in considering your application.

Note to Applicants: DO NOT ANSWER THIS QUESTION BELOW UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING.

Can you perform the essential functions of the job, for which you are applying, either with or without a reasonable accommodation?

Yes

References

Reference 1 Name

Reference First and Last Name

Reference 1 Telephone Number

Enter a phone number in the following format: 000-000-0000

Reference 1 Address

Enter the address, city, state and zip code

Reference 2 Name

Reference First and Last Name

Reference 2 Telephone Number

Enter a phone number in the following format: 000-000-0000

Reference 2 Address

Enter the address, city, state and zip code

Applicant's Statement

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 in 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 other wise 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 the Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of 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 the employer.

Signature of Applicant

Date Completed

Enter the date in the following format: dd/mm/yyyy

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