subject_line
Join Stedman-Wade Health Services Inc.
Personal Information
First Name
*
Last Name
*
Address 1
*
Address 2
City
*
State
*
Zip Code
*
Phone
*
Email Address
*
Position Applying For
*
Patient Care Representative
Medical Assistant
Dental Assistant I
Dental Assistant II
General Dentist
LCSW (fully licensed)
Accounting Specialist I
Dental Billing Specialist/Front Desk Receptionist
Insurance Billing Clerk
Staff Physician
Case Manager/Resource Developer
Advanced Practice Provider
Referral Source
Employee
Company's Website
Social Media Ad
School
Other
Are you legally authorized to work in the United States?
*
Yes
No
Have you submitted an application here before?
*
Yes
No
If yes, give dates:
Have you ever been employed here before?
*
Yes
No
If yes, give dates:
Date available for work:
*
What is your desired salary range or hourly rate of pay?
*
Type of employment desired:
*
Full-Time
Part-Time
Are you able to perform the "essential functions" of the job for which you are applying (with or without reasonable accommodation)?
*
Yes
No
Need more information about the job's "essential functions" to respond
Have you ever pleaded "guilty" or "no contest" to or been convicted of a crime?
*
Yes
No
If yes, please provide date(s) and details:
Availability
Days Available (if applying for a part-time position)
Monday
Tuesday
Wednesday
Thursday
Friday
Employment History
Employer 1
Company Name
*
Address
*
Phone
*
Start Date
*
+
End Date
*
+
Position
*
Salary
*
Supervisor/Manager and title (for most recent position held)
*
Reason for Leaving
*
Summarize the type of work performed and job responsibilities.
*
What did you like most about your position?
*
What were the things you liked least about the position?
*
May we contact?
*
Yes
No
Later
Phone Number
*
Employer 2
Company Name
Address
Phone
Start Date
+
End Date
+
Position
Salary
Supervisor/Manager and title (for most recent position held)
Reason for Leaving
Summarize the type of work performed and job responsibilities.
What did you like most about your position?
What were the things you liked least about the position?
May we contact?
Yes
No
Later
Phone Number
Employer 3
Company Name
Address
Phone
Start Date
+
End Date
+
Position
Salary
Supervisor/Manager and title (for most recent position held)
Reason for Leaving
Summarize the type of work performed and job responsibilities.
What did you like most about your position?
What were the things you liked least about the position?
May we contact?
Yes
No
Later
Phone Number
Explain any gaps in your employment, other than those due to personal illness, injury or disability.
If not addressed on previous page, have you ever been fired or asked to resign from a job?
*
Yes
No
If yes, please explain:
References
Reference 1
Name
*
Title
*
Email Address
*
Phone
*
Reference 2
Name
*
Title
*
Email Address
*
Phone
*
Reference 3
Name
*
Title
*
Email Address
*
Phone
*
Education
Starting with your most recent school attended, provide the following information.
School name (City, State)
*
Year Completed
*
Major/Minor
*
Completed
*
Diploma
GED
Degree
Certification
Other
School Name (City, State)
Year Completed
Major/Minor
Completed
Diploma
GED
Degree
Certification
Other
School Name (City, State)
Year Completed
Major/Minor
Completed
Diploma
GED
Degree
Certification
Other
School Name (City, State)
Year Completed
Major/Minor
Completed
Diploma
GED
Degree
Certification
Other
Skills & Qualifications
List any additional skills or special accomplishments that you would like to mention.
Do you have a current CPR or BLS card?
*
Yes
No
If yes, what's the expiration date?
Please submit a copy of your resume.
Powered by