Job Application Form

Position You are Applying For:*
—Please choose an option—Medical Receptionist/Front DeskMedica AssistantMedical Office AssistantMedical Billing SpecialistCredentialing SpecialistOffice MangerPractice Manager

Date Available For Work:

Desired Salary Amount

Desired Salary Frequency
AnnuallyMonthlyBi-WeeklyWeeklyHourly

Last Name:*

First Name:*

Middle Name:

Address:*

City:*

State:*
—Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip:*

Home Phone:

Cell Phone:*

Email:*

Are you a U.S. Citizen? * YesNo

Have you ever been convicted of a felony? * YesNo

If selected for employment are you willing to submit drug screening test? * YesNo

School Name:

Location

Years Attended

Degree Received
—Please choose an option—CertificateAssociate DegreeBachelor's DegreeMaster's DegreeDoctoral DegreeOther

Major

—Please choose an option—CertificateAssociate DegreeBachelor's DegreeMaster's DegreeDoctoral DegreeOther

—Please choose an option—CertificateAssociate DegreeBachelor's DegreeMaster's DegreeDoctoral DegreeOther

Employer:*

Start Date:*

End Date:

Position:*

Work Phone:*

Salary:

Salary Frequency
AnnuallyMonthlyBi-WeeklyWeeklyHourly

Work Address:*

City:*

State:*
—Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip:*

Supervisor’s full name

Supervisor’s Title

Reasons for leavinng:

May we contact them? * YesNo

Full Name:*

Title:*

Company:*

Phone:*

Full Name:*

Title:*

Company:*

Phone:*

Full Name:*

Title:*

Company:*

Phone:*

Attach Resume (Optional and Max file size is 5MB)

I certify that all answers given herein are true and complete to the best of my knowledge

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

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge