Medical Documentation Representative - South Bend Application

Home Careers Medical Documentation Representative - South Bend

* - Indicates required fields

Personal Information

Position(s) Applied For*

Telephone Number*

Cell Number

Alternate Number

Last Name*

First Name*

Middle Name

Address*

City*

State*

Zip Code*

Email Address*

How did you hear about us: Newspaper Ad Internet Current Employer (Enter name below) College (Enter name below) Other (Enter source below)

Education

High School

School Name

City/State

# years completed

Did you graduate? Yes No

Degree Earned? Diploma GED

Undergraduate College

School Name

City/State

# years completed

Did you graduate? Yes No

Degree Earned?

Major

Graduate Professional

School Name

City/State

# years completed

Did you graduate? Yes No

Degree Earned?

Major

Other

School Name

City/State

# years completed

Did you graduate? Yes No

Degree Earned?

Major

Employment History

Employer Name

Address

Phone Number

Supervisor's Name

May we contact for reference? Yes No

Date Employed

From (MO/YR)

To (MO/YR)

Salary

Starting

Final

Status Full-time Part-time

Last Job Title

Summary of Duties

What did you like most/least about your position?

Reason for Leaving

Employer Name

Address

Phone Number

Supervisor's Name

May we contact for reference? Yes No

Date Employed

From (MO/YR)

To (MO/YR)

Salary

Starting

Final

Status Full-time Part-time

Last Job Title

Summary of Duties

What did you like most/least about your position?

Reason for Leaving

Employer Name

Address

Phone Number

Supervisor's Name

May we contact for reference? Yes No

Date Employed

From (MO/YR)

To (MO/YR)

Salary

Starting

Final

Status Full-time Part-time

Last Job Title

Summary of Duties

What did you like most/least about your position?

Reason for Leaving

Employer Name

Address

Phone Number

Supervisor's Name

May we contact for reference? Yes No

Date Employed

From (MO/YR)

To (MO/YR)

Salary

Starting

Final

Status Full-time Part-time

Last Job Title

Summary of Duties

What did you like most/least about your position?

Reason for Leaving

Employer Name

Address

Phone Number

Supervisor's Name

May we contact for reference? Yes No

Date Employed

From (MO/YR)

To (MO/YR)

Salary

Starting

Final

Status Full-time Part-time

Last Job Title

Summary of Duties

What did you like most/least about your position?

Reason for Leaving

Specialized Training & Activities

Describe any specialized training, apprenticeshps, licenses, or skills that you feel may be relevant to the job you are seeking:

Activities (Civic, Athletic, etc.):

General Information

Are you legally authorized to work in the United States?*

Are you legally authorized to work in the United States?* (If hired, verification will be required upon employment)

Yes No

Are you 18 years of age or older?*

Are you 18 years of age or older?*

Yes No

Have you ever applied with Alick's Home Medical, Inc before?

Have you ever applied with Alick's Home Medical, Inc before?*

Yes No

If yes, When?

Have you ever worked for Alick's Home Medical, Inc before?

Have you ever worked for Alick's Home Medical, Inc before?*

Yes No

If yes, When?

Do you have any relatives currently working for for Alick's Home Medical, Inc?*

Do you have any relatives currently working for for Alick's Home Medical, Inc?*

Yes No

If yes, please list name(s)?

Have you ever been convicted of a felony which has not been expunged or sealed by a court?*

Have you ever been convicted of a felony which has not been expunged or sealed by a court?*

Yes No

If yes, please explain?

Have you ever been fired or asked to resign from a job?*

Have you ever been fired or asked to resign from a job?*

Yes No

If yes, please explain?

What salary rate of pay do you expect to receive if employed?

On what date would you be available to work?

REFERENCES

Name

Phone Number

Relationship/Occupation

Years Known

Name

Phone Number

Relationship/Occupation

Years Known

Name

Phone Number

Relationship/Occupation

Years Known

Upload Resume

Upload your Rèsumè:*

APPLICANT ACKNOWLEDGEMENT AND AUTHORIZATION:-
IMPORTANT: Read before signing.

I have read and fully understand the questions asked in this application. I certify that all answers given by me are true, accurate, and complete. I hereby authorize Alick's Home Medical, Inc to obtain employment and educational references for me from all current and prior employers and educational institutions and release all persons from liability for providing such reference information. I hereby release Alick's Home Medical Inc from any/all liability of whatever kind and nature, which at any time, could result from obtaining and basing an employment decision on such information. I understand that, if employed, Alick's Home Medical Inc may terminate my employment if I have made any false statements or misrepresentations in this application or during the interview process.

I understand that should an employment offer be extended to me and accepted that I will fully adhere to the policies, rules and regulations of employment of Alick's Home Medical Inc. However, I further understand that neither the policies, rules, or regulations of employment nor anything said during the interview process shall be deemed to constitute the terms of an implied employment contract. I understand that any employment offered is for an indefinite duration and at will and that either Alick's Home Medical Inc or I may terminate my employment at any time with or without notice or cause. I understand that Alick's Home Medical and all plan administrators shall have the maximum discretion permitted by law to administer, interpret, modify, discontinue, enhance, or otherwise change all policies, procedures, benefits, or other terms or conditions of employment

My signature below indicates that I have read, understand, and agree to the above statements.

Signature of Applicant*

Date

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