Employment Application

Position applied for:		Status Prefered
Who referred you to this Center?		Shift Preference
Minimum Salary Requirement

Have you ever worked at this Center before?	When?	Position?

Have you ever applied at this Center before?	When?	Please explain:

Last Name	First Name	Middle Initial	Social Security Number

Residence Address	City	State	Zip	How Long?

Email Address		Telephone

Type	State	Renewal Date	Expiration Date

Type	State	Renewal Date	Expiration Date

Type	State	Renewal Date	Expiration Date

Have you ever been in the U.S. armed forces?		Length of military service
		From: To:
Have you ever been bonded?
Have you ever been convicted of a felony?		If yes, what was the felony?

When was the felony committed?		What was the outcome?

Have you ever been terminated from or asked to resign from a position? If yes, explain:

Emergency Contact Name	Phone Number

Name of Employer		From:	To:

Street	City	State	Zip

Position		Position(s) Held

Explain your duties, responsibilities and number of people supervised, if any:

Why did you leave?

Name of supervisor?	Phone Number	May we contact?




Name of Employer		From:	To:

Street	City	State	Zip

Position		Position(s) Held

Explain your duties, responsibilities and number of people supervised, if any:

Why did you leave?

Name of supervisor?	Phone Number	May we contact?




Name of Employer		From:	To:

Street	City	State	Zip

Position		Position(s) Held

Explain your duties, responsibilities and number of people supervised, if any:

Why did you leave?

Name of supervisor?	Phone Number	May we contact?




Name of Employer		From:	To:

Street	City	State	Zip

Position		Position(s) Held

Explain your duties, responsibilities and number of people supervised, if any:

Why did you leave?

Name of supervisor?	Phone Number	May we contact?

Name and Address	Telephone

Name and Address	Telephone

Name and Address	Telephone

Name and Address	Telephone

Name and Address	Telephone

Name and Address	Telephone

High School and/or G.E.D. Name	Address	Highest Grade Completed	Grade Point Average

Did you graduate?	If yes, what was your major study?	Last year of study?

College Name	Address	Highest Grade Completed	Grade Point Average

Did you graduate?	If yes, what was your degree and major?	Last year of study?

Trade or Business School Name	Address	How Long?	Grade Point Average

Did you graduate?	If yes, what was your major study?	Last year of study?

List other training you have had:

Extracurricular Activities, Offices held:

Academic honors or special recognition:

Current Memberships in Professional Organizations:

Past Memberships in Professional Organizations:

Sports, Hobbies and other interests:

Have you had experience in the following?		Length of Time?
Accounting
Billing and Collecting
Medical Records
Managed care contracting
Computers	Types:
Shorthand
Typing	Average Words Per Minute:
Diction
Other

SUMMARY OF QUALIFICATIONS

In this space you briefly summarize any additional qualifications you feel are important in considering your application for employment

I fully understand that any significant misstatements in or omissions from this application constitute cause for denial of employment or cause for dismissal from employment. All information submitted by me in this application is true to the best of my knowledge and belief.

I hereby authorize any inquiry to be made by the information contained in this application, and authorize any individual contacted during this inquiry to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from providing this information.

If any employment agreement is established, I agree to conform to all the rules and regulations of this Center and I understand that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at the option of the Center.

Yes No

Date