Employment Application

Employment Application
Name*
DOB
SSN
Address

Address

Street Address Line 2

City/State/ZipState / Province

Postal / Zip Code
Email
example@example.com
Telephone
What positions are you applying for?

RBTBCaBABCBAOther
How did you hear about this position?
Expected hourly rate
Date Available

MonthDayYear
Date
Availability: mark x the days/times you are available to work

Mon AMMon PMTue AMTue PMWed AMWed PMThu AMThu PMFri AMFri PMSat AMSat PM
Name the areas/zones where you are interested to work (e.g., downtown, doral, 33129, homestead, any zone)
Are you currently a provider to any of the following insurances?

FL MedicaidTricareAetnaOther
Other
Education
What is your highest educational level?

High SchoolAssociateBachelorMastersPh. D
School/College/University
Degree/Major
Month/Year of completion
Are you currently enrolled in school, college, or university?

YesNo
School/College/University
Degree/Major
Last year complete
English language proficiency

PoorFairGoodVery GoodExcellent
Second language proficiency (if any)

PoorFairGoodVery GoodExcellent
Name, if applicable
Do you have any experience with Electronic Health Records (HER) software?

YesNo
List any applicable special skills or advance training
Work Experience
Current or most recent job
Employer
From
To
Address
Immediate Supervisor Name/phone number
Position/Job Title
Pay rate
Immediate Supervisor Name
Immediate Supervisor Phone
May we contact?

YesNo
Reason for leaving, if applicable
Prior employment
Employer
From
To
Address
Phone
Pay rate
Position/Job Title
Immediate Supervisor Name
Immediate Supervisor Phone Number
May we contact?

YesNo
Reason for leaving, if applicable
Are you an US citizen?

YesNo
Are you entitled to work in the United State?

YesNo
US Military Service?

YesNo
Branch
Have you ever had a provider number denied, revoked, suspended. or terminated? If yes, please explain:

YesNo
If yes, please explain
Have you ever had a professional license revoked, suspended, or terminated?Yes If yes, please explain:

YesNo
If yes, please explain
Have you been arrested?

YesNo
If yes, please explain
Have you been convicted of a felony or been incarcerated in connection with a felony?

YesNo
If yes, please explain
By signing. / hereby certify that the above information, to the best of my knowledge, is correct. / understand that falsification of this information may prevent me from being hired or lead to my dismissal if hired.
Applicant Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Employment Application

Education

Work Experience

Current or most recent job

Prior employment