"*" indicates required fields Applicant InformationName: (last, first, middle)* First Current date: MM slash DD slash YYYY Address: both mailing and street* Street Address City State / Province / Region ZIP / Postal Code Home phone/ cell phone*Email: Are you younger than 18? Yes No Social security Are you a US citizen or legally authorized to work in the United States? Yes No PositionPosition you are applying for: Date available:* MM slash DD slash YYYY Additional InformationDo you have relatives employed here? Yes No With or without accomodations, can you perform the essential functions of the position for which you are applying? Yes No If No, please explain:Education Indicate the highest level completed: GED High School Diploma CollegeHigh SchoolHigh School, name, complete address & phoneName under which you received your diploma/GED Add RemoveCollegeCollege: name, complete address & phoneName under which you received degreeDate ReceivedType of degreeMajor Add RemoveOther trainingList other trainingSubjectDates fromDates to Add RemoveWork ExperienceEmployerEmployerAddressPositionDates toDates from Add RemoveReason for leavingSupervisorsSupervisors name and titlePhone Add RemoveIt is our practice to contact prior employers to verify dates of employment. Is there any employer that you would not like us to contact? Please explain why:Skills, Certifications / Licenses Please check the items indicating which of the following skills you have:Typing speed (WPM) Electronic Health Record Calculator (KPM) EHR programs used: Multi-line phone ICD 9-10 coding Medical Records CPT coding Medical Terminology Other: Professional Certifications / LicensesDo you currently possess the required professional license, certification, registration or permit for the position (s) you are applying for? Yes No If yes, type:NumberStateExpires Add RemoveIf no, have you applied? Yes No Date applied: MM slash DD slash YYYY Professional References Do not list relativesPROFESSIONAL REFERENCESNameEmail addressHome/cellWork phoneRelationship Add RemoveI certify the information given in this application for employment is true and complete to the best of my knowledge. I authorize Cascade Orthopedic Specialists to verify my education credentials and professional licenses and to make inquiry of my former employer or references as to my experience, job suitability and/or reasons for leaving. I understand that if employed, the making of false statements on this application or omission of information on any other form will be sufficient cause for my dismissal. I understand that my employment is contingent upon proof of identity and verification of eligibility for employment in the United States.SIGNATURE OF APPLICANT*DATE MM slash DD slash YYYY PLEASE PRINT FULL NAME* It is the policy of this organization to provide equal employment opportunity to all qualified applicants for employment without regard to race, color, religion, national origin, sexual orientation, gender, age, veteran status or disability.
