First Name:

Middle Initial:

Last Name:

Phone #:

Cell #:

E-mail Address:

Are you 18 year or older? Yes No

Present Address:

City:

State:

Zip Code:

Permanent Address:

City:

State:

Zip Code:

If you currently live our of state, are you moving to New York? Yes No

Are you precented from lawfully becoming employed in this country because of visa or immigration status? Yes No

Position: Select A Position Pediatrician Registered Nurse Licensed Practical Nurse Medical Assistant Receptionist Record Clerk Biller Managed Care Coordinator Secretary Clinical Student Clerical Student

Salary Desired:

Date you can start: 00/00/00

Hours Desired: Full-Time Part-Time Part-Time/Full-Time

Are you employed now? Yes No

If so, may we inquire of your present employer? Yes No

Ever applied to this company before? Yes No

Where?

When?

Referred by:

High School

Name:

Number of years attended:

Did you graduate? Yes No

Subjects Studied:

College

Name:

Number of years attended:

Did you graduate? Yes No

Subjects Studied:

Trade/Business

Name:

Number of years attended:

Did you graduate? Yes No

Subjects Studied:

Subjects of special study or research work:

Special Skills:

Activities (Civic, Athletic, etc.):

U.S. Military or Naval Service:

Rank:

Present Membership in National Guard or Reserves:

Employer Name:

Date From:

Date To:

Address:

Salary:

Position:

Responsibilities:

Reason for leaving?

Employer Name:

Date From:

Date To:

Address:

Salary:

Position:

Responsibilities:

Reason for leaving?

Employer Name:

Date From:

Date To:

Address:

Salary:

Position:

Responsibilities:

Reason for leaving?

Which of these jobs did you like the best?

What did you like most about this job?

Give the names of three persons not related to you, whom you have known at least one year.

Name:

Address:

Business:

Years Acquainted:

Name:

Address:

Business:

Years Acquainted:

Name:

Address:

Business:

Years Acquainted: