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Call Us: 301-874-3431
About
Conditions & Treatments
Conditions
Treatments
Request an Appointment
Patient Information
Contact Us
Menu
About
Conditions & Treatments
Conditions
Treatments
Request an Appointment
Patient Information
Contact Us
Job Application Form
Interventional Pain and Spine Care Job Application
Position You are Applying For:
*
—
Medical Receptionist/Front Desk
Medica Assistant
Medical Office Assistant
Medical Billing Specialist
Credentialing Specialist
Office Manger
Practice Manager
Date Available For Work:
Desired Salary Amount
Desired Salary Frequency
Annually
Monthly
Bi-Weekly
Weekly
Hourly
PERSONAL INFORMATION
Last Name:
*
First Name:
*
Middle Name:
Address:
*
City:
*
State:
*
—
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
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Hawaii
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Maryland
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Ohio
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Vermont
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Washington
West Virginia
Wisconsin
Wyoming
Zip:
*
Home Phone:
Cell Phone:
*
Email:
*
Are you a U.S. Citizen?
*
Yes
No
Have you ever been convicted of a felony?
*
Yes
No
If selected for employment are you willing to submit drug screening test?
*
Yes
No
EDUCATION
School Name:
Location
Years Attended
Degree Received
—
Certificate
Associate Degree
Bachelor's Degree
Master's Degree
Doctoral Degree
Other
Major
—
Certificate
Associate Degree
Bachelor's Degree
Master's Degree
Doctoral Degree
Other
—
Certificate
Associate Degree
Bachelor's Degree
Master's Degree
Doctoral Degree
Other
EMPLOYMENT
Employer:
*
Start Date:
*
End Date:
Position:
*
Work Phone:
*
Salary:
Salary Frequency
Annually
Monthly
Bi-Weekly
Weekly
Hourly
Work Address:
*
City:
*
State:
*
—
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip:
*
Supervisor’s full name
Supervisor’s Title
Reasons for leavinng:
May we contact them?
*
Yes
No
REFERENCES
Full Name:
*
Title:
*
Company:
*
Phone:
*
Full Name:
*
Title:
*
Company:
*
Phone:
*
Full Name:
*
Title:
*
Company:
*
Phone:
*
Resume Attachment
Attach Resume (Optional and Max file size is 5MB)
Acknowledgement and Authorization
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
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