Office Staff Job Application
Thank you for taking the time to submit a job application. We are very excited to learn more about you and are looking forward to meeting with you soon! All applicants are subject to a background search. Applicants may be tested for illegal drugs.
Today's Date
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-
Month
-
Day
Year
Date
What position are you applying for?
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Office Assistant / Manager
Bilingual Receptionist (English & Spanish)
Cleaning Technician
Medical Biller
Other
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How long have you lived at the above address?
*
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
What is your desired salary / hourly rate?
*
What are the days and hours you are available to work?
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
8:00am
9:00am
10:00am
11:00am
12:00pm
1:00pm
2:00pm
3:00pm
4:00pm
5:00pm
6:00pm
COVID-19 Vaccination Status
Federal mandate required all healthcare workers and support staff working in facilities that participate in Medicare of Medicaid programs to be fully vaccinated against COVID-19. Employees may request religious and medical exemptions.
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Fully vaccinated (2 doses of Pfizer or Moderna, or 1 dose of Johnson & Johnson)
Partially vaccinated or planning to get vaccinated
Interested in applying for exemption secondary to medical or religious reasons
What is your highest level of education completed?
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High School
College
Graduate School
Other
Name and Location of School, Years Completed, and the Major/Degree?
*
Have you ever been convicted of a crime?
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Yes
No
If yes to the above question, please list the number(s) of convictions, nature of offense(s), and date(s):
*
Please list any other relevant information that may be found in a background check:
*
Do you have a driver's license?
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Yes
No
Driver's License State & Number (if applicable)
Please list two references other than close friends or relatives. For each reference, please include their name, position, company, address, and phone number.
*
Are you now a member of the National Guard or Reserves?
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Yes
No
If yes to the above question, what is your discharge date?
*
Work Experience
Work Experience 1
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Work Experience 2
Work Experience 3
May we contact your present employer?
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Yes
No
Please choose one characteristic which you identify more with:
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Introverted
Extroverted
Please choose one characteristic which you identify more with:
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Task-Oriented
People Oriented
Please choose one characteristic which you identify more with:
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Laid Back
Assertive
Please choose one characteristic which you identify more with:
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Playful
Serious
In terms of my career, in one (1) year, I would like to see myself:
*
Use the space below to summarize any additional information that you would like to share with us:
Please Upload Your Resume
*
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