Employment Application Form

TANYR Healthcare Employment

Fill the form below accurately indicating your potentials and suitability to the job you are applying for.
Applicant Information
Desired Position - Choose all that apply:

Insurance Verification Billing Collections - Insurance Collections - Patient Balance Cash Application
Name: *

First Name Middle Name Last Name
Birth Date

Month Day Year
Phone Number: *

Area Code Phone Number
E-mail Address:
Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Shifts Available *

Any Day Night
Desired Status *

Full Time Part Time
If hired, can you provide written evidence that you are authorized to work in the U.S. *

Yes No
General Information
Have you worked for TANYR Healthcare before? *

Yes No
Is there any information we would need about your name, or use of another name, for us to be able to check your work record? *

Yes No
If yes, please specify:
Are you related to anyone employed by TANYR Healthcare? If yes, please list:
Have you pleaded guilty to or been convicted of a crime other than minor traffic accidents? *

Yes No
(Note: Conviction of a criminal offense will not necessarily preclude your employment) If yes, please describe in full:
Are you able to perform the essential functions of the job, with or without a reasonable accomodation? *

Yes No
If your application is considered favorably, on what date will you be available for work?

Month Day Year
How did you hear about us? *

Indeed LinkedIn TANYR Employee
If you have been referred by a TANYR employee, please provide their name:
Education
Have you earned a high school or general education diploma? *

Yes No
If yes, specify name and location of school:
Have you earned a college degree? *

Yes No
Degree Earned:
If no degree, indicate any credit hours:
School name and location:
Have you had vocational or special training? *

Yes No
If yes, specify name and location of school:
Area of study or specialization and license (if applicable):
Please list any additional information that relates to your ability or perform the job for which you have applied such as licenses, certifications, professional memberships, hobbies, etc.
Employment Record

Indicate your past work experience starting with your most recent employment and account for the last five years of employment (including any employment lapses).
Present / last employer:
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number *

Area Code Phone Number
Job title:
Pay rate:
Reason for leaving:
May we contact your present employer for a reference?

Yes No
Previous employer:
Phone Number

Area Code Phone Number
Pay rate:
Reason for leaving:
Previous employer:
Phone Number

Area Code Phone Number
Pay rate:
Reason for leaving:
References

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

First Name Last Name
Phone Number

Area Code Phone Number
Years Known:
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Reference 2
Name:

First Name Last Name
Phone Number

Area Code Phone Number
Years Known:
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Please upload your resume *

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TANYR Healthcare Employment

Applicant Information

General Information

Education

Employment Record

References

Reference 1

Reference 2