Intern Application Form

Name:

First NameLast Name

Birth Date

MonthDayYear

Phone Number:

Area CodePhone Number

E-mail Address:

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How were you referred to us?

Other

Upload Resume:

Upload a File

Position

I can commit to an on-site/in person Internship Monday-Friday from 8am-4pm?

Other

I understand that this is a non-paid Internship only to help me gain experience and not a job offer?

Name of School for Medical Billing & Coding

Graduation Certificate Month and Year

Why do you want to intern for us ?

What do you do to stay up to date on healthcare/billing issues ?

Have you applied for jobs since you graduated? If so, which companies? what was the outcome?

Which healthcare related groups, websites, forums do you subscribe to? Including but not limited to social media, email, etc

Are you currently working ? If yes, please explain your current job