Employment Application Form

ELEMENT MEDICAL BILLING, LLC APPLICATION FOR EMPLOYMENT

Element Medical Billing, LLC is an equal opportunity employer. Element Medical Billing, LLC does not discriminate in employment with regard to race, color, religion, national origin, citizenship status, ancestry, age, sex (including sexual harassment), sexual orientation, marital status, physical or mental disability, military status or unfavorable discharge from military service or any other characteristic protected by law.
Date

MonthDayYear
Date
All positions are Full-Time
Name*

First NameMiddle NameLast Name
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone

Area CodePhone Number
Mobile Phone*

Area CodePhone Number
E-mail Address:*
Position Applied For:*
Days/Hours available to work:*
Salary desired*
Can you work evenings?*
Employment desired:*
When are you available to start work?*

Education

Rows	Name of School	Location	Years Completed	Major & Degree
Type of School
High School
College
Business or Trade School
Professional or Graduate

Employment History

Please list your work experience for the past 5 years beginning with your most recent job held. If you were self -employed, give firm name.
Current or Most Recent Employer:*
Name of Employer
Address*
City & State
Last position held
Immediate Supervisor
Name & Department
Phone number*
Dates of Employment *

FromTo
Job title and responsibilities:*
Reason for leaving:*
Please be specific
May we Contact this Employer?*
Next Most Recent Employer:*
Name of Employer
Address*
City & State
Last position held
Immediate Supervisor
Name & Department
Phone number
Dates of Employment

FromTo
Job title and responsibilities:
Reason for leaving:
Please be specific
May we Contact this Employer?*
Next Most Recent Employer:*
Name of Employer
Address*
City & State
Last position held
Immediate Supervisor
Name & Department
Phone number
Dates of Employment

FromTo
Job title and responsibilities:
Reason for leaving:
Please be specific
References

Please list two references that are familiar with your work life.
Reference 1
Name:*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Years Known:*
Profession
Reference 2
Name:*

First NameLast Name
Phone Number*

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

1. Can you provide proof of eligibility to become employed in the United States?*
2. If you are under the age of 18, can you provide required proof of your eligibility to work?*
3. Are you currently employed?*
4. Have you ever been in the armed forces?*
5. Do you have adequate transportation?*
Private or public transportation
6. Do you have friends or relatives employed by EMB?*
If yes, please provide names and relationship below:
Current Employee Name

NameRelationship
7. Are you aware of any reason that may restrict your ability to perform the essential functions of the job for which you are making application?*
If yes, please explain and describe what accommodations might be necessary:
8. Have you ever been terminated or forced to resign from your employment with any employer?*
If yes, please explain:
9. Have you ever been convicted of a felony?*
If yes, please explain charges and dates:

Please read carefully before signing.

I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for Element Medical Billing, LLC to hire me. If I am hired, I understand that either Element Medical Billing, LLC or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of Element Medical Billing, LLC has the authority to make any assurance to the contrary.

I attest with my signature below that I have given to Element Medical Billing, LLC true and complete information on this application. No requested information has been concealed. I authorize Element Medical Billing, LLC to contact references provided for employment reference checks. If any information I have provided is untrue, or if I have concealed material information, I understand that this will constitute cause for the denial of employment or immediate dismissal.
Signature

Clear
Phone Number Disclaimer & Opt-In Consent
By providing your phone number on this job application, you consent to receive communication from Element Medical Billing regarding your job application, interview scheduling, and any updates related to your candidacy. This may include text messages, phone calls, or other forms of communication.
Your phone number will be used solely for purposes related to the recruitment process and will not be shared with third parties outside of Element Medical Billing without your explicit consent, unless required by law.
You may opt out of receiving communication at any time by notifying Element Medical Billing in writing or by replying to any communication you receive.
By submitting this application, you acknowledge and agree to the above terms. For more please see our privacy policy as well as Terms of service

Privacy Policy
Should be Empty:

Employment History

References

Reference 1

Reference 2