Employment Application Form

Employment Application
Cornerstone Psychiatric Services, Inc.
1790 E. Venice Ave. Ste 204
Venice, FL 34292
(941) 488-8884
Applicant Name:*

First NameLast Name
Phone Number:*
E-mail Address:*
Address:*

Street Address

Street Address Line 2

CityState

Zip Code
How were you referred to us?*

IndeedWalk-InEmployeeOther (please specify)
Others:
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Your Last Job Title/Position:*
Start and End Date of this job? If you are currently working at this job, enter end date you plan to stop working your current job.
In regards to your last job, you were paid:*

Hourly RateSalary (monthly)Salary (annual)Other
Other Salary pay, please provide details:*
What was your beginning rate of pay? ($/per hour or salary)*
What was your ending salary of your last job? ($/per hour)*
Reason for leaving last job?
What position are you applying for?*

Medical ReceptionistNurse Practitioner (APRN)Licensed Clinical Social Worker (LCSW)

	YES	NO
Are you a citizen of the United States?
If not a U.S. Citizen, are you authorized to work in the U.S.?
Have you ever worked for this company?
Have you ever been convicted of a felony?

If you answered 'YES' to ever been convicted of felony, please explain:
Have you had experience in the following?*

TypingFilingAnswering phone callsScheduling AppointmentsMedical TerminologyPsychiatric or Mental Health TerminologyPrescription TerminologyWord ProcessingInsurance FilingInsurance VerificationElectronic BillingMedical Software / EHR useAccounts ReceivableAccount Collections / Collecting of CopaysOther
Job Skills & Training
Describe your skills:*
Training or Certifications:
References

Please list two (2) references that are familiar with your work life.
Reference 1
Name of 1st Reference:*

First NameLast Name
Phone Number*
Mobile Number

Area CodePhone Number
Email
example@example.com
Years Known:*
Address

Street Address

Street Address Line 2

CityState

Zip Code
Reference 2
Name of 2nd Reference:*

First NameLast Name
Phone Number*
Mobile Number

Area CodePhone Number
Email
example@example.com
Years Known:*
Address

Street Address

Street Address Line 2

CityState

Zip Code
I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I undertand that false or misleading information in my application or interview may result in my release.
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