Step 1 - Applicant Information

Name*

Email*

Street*

City*

State*

Zip Code*

Phone Number*

Date Available to Begin*

Social Security Number

Which position are you applying for? *
Medical Office ReceptionistMedical AssistantBilling TeamProvider

Desired Pay (Please indicate salary or hourly rate) *
[cf7mls_step cf7mls_step-1 "Next Step: Employment Eligibility" ""]

Step 2 - Employment Eligibility

Are you legally eligible to work in the United States? *
YesNoOther

Have you ever worked for this company? *
YesNoOther
Have you ever been convicted of a felony?*
YesNo

[cf7mls_step cf7mls_step-2 "Back to Applicant Information" "Next Step: Education" "Step 2"]

Step 3 - Education

High School

High School*

Address

Did you graduate?*
YesNo

College

College*

Address

Did you graduate?*
YesNo[cf7mls_step cf7mls_step-3 "Back to Employment Eligibility" "Next Step: References" "Step 3"]

Step 4 - References

Reference 1

Full Name and Relationship*

Company, address, and phone number*

Reference 2

Full Name and Relationship*

Company, address, and phone number*

Reference 3

Full Name and Relationship*

Company, address, and phone number*[cf7mls_step cf7mls_step-4 "Back to Education" "Next Step: Previous Employment" "Step 4"]

Step 5 - Previous Employment

Company 1

Company Name*

Address*

Phone*

Supervisor*

Job Title*

Responsibilities*

Reason for leaving*

Company 2

Company Name*

Address*

Phone*

Supervisor*

Job Title*

Responsibilities*

Reason for leaving*

May we contact your previous supervisor for a reference?*
YesNo[cf7mls_step cf7mls_step-5 "Back to References" "Next Step: Military Service (Optional)" "Step 5"]

Military Service (Optional)

Branch

Rank at discharge

DISCLAIMER AND SIGNATURE
I CERTIFY THAT MY ANSWERS ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
IF THIS APPLICATION LEADS TO MY EMPLOYMENT, I UNDERSTAND THAT FALSE OR MISLEADING INFORMATION IN MY APPLICATION OR INTERVIEW MAY RESULT IN MY RELEASE.

[cf7mls_step cf7mls_step-6 "Back to Previous Employment" "Step 6"]