Position Applying For:
Last Name:
Street Address:
City:
State:
Zip:
Phone:
First Name:
Last four digits of SSN:
Referred by:
Preferred Worktype:
Preferred Work Days:
Preferred Work Times:
YOUR EXPERIENCE:
Consultations - # of years:
Operative Notes - # of years:
Discharge Summaries - # of years:
Progress Notes - # of years:
ER - # of years:
GI - # of years:
Oncology - # of years:
Pathology - # of years:
Radiology - # of years:
Cardiology - # of years:
Clinic/ Office Notes - # of years:
Psychiatry - # of years:
Neurology - # of years:
Special Procedures - # of years:
Other (please specify) - # of years:
OB/GYN - # of years:
Operating System:
YOUR COMPUTER
Amount of RAM:
Processor/Speed:
Hard Drive Size:
Word Processing Program:
Type of Internet Connection:
Software Platforms:
WORK HISTORY/
REFERENCES:
Most Recent/Current Employer:
Phone Number:
Web Address:
Contact Person:
Start/End Dates (mm/yy - mm/yy):
Position:
Reason for Leaving:
Previous Employer:
Phone Number:
Position:
Contact Person:
Previous Employer:
Phone Number:
Web Address:
Contact Person:
Previous Employer:
Phone Number:
Web Address:
Contact Person:
Notification and Agreement
(Please read before submitting)
I CERTIFY THAT ALL ANSWERS GIVEN BY ME ARE TRUE, ACCURATE AND COMPLETE. I UNDERSTAND THAT THE FALSIFICATION, MISREPRESENTATION OR OMISSION OF FACT ON THIS APPLICATION (OR ANY OTHER ACCOMPANYING OR REQUIRED DOCUMENTS) WILL BE CAUSE FOR DENIAL OF ACCEPTANCE, TERMINATION FROM THE PROGRAM, DENIAL OF EMPLOYMENT AT THE COMPLETION OF THE INTERNSHIP OR IMMEDIATE TERMINATION OF EMPLOYMENT, REGARDLESS OF WHEN OR H0W DISCOVERED.
It is the policy of this company to afford equal opportunity to all employees and applicants for employment without regard to age, race, religion, color, sex, national origin, marital status, expunged juvenile records or pregnancy, and to afford equal opportunities to disabled veterans, veterans of the Vietnam era, individuals with a disability and any other characteristic protected by Federal, State or Local law.
I authorize the investigation of all statements and information contained in this application. I release from all liability anyone supplying such information and I also release the employer from all liability that might result from making an investigation.
If hired, I agree to abide by all of the company rules and regulations. I understand that, if employed, my employment may be terminated with or without cause and with or without notice, at any time, at the option of either the company or me. I further understand that no representation, whether oral or written by any representative or agent of the Company, at any time, can constitute a contract of employment.
I acknowledge that I have read and understand the above statements and hereby grant permission to confirm the information supplied on this application by me.
I certify that I am a resident of the United States and am eligible to be legally employed in the United States
By typing your name below, this will serve as your electronic signature and be considered as such an equivalent.
YOUR RESUME
(COPY & PASTE):
Applicant Signature:
APPLICATION FOR IC POSITION
Email address:
Start/End Dates (mm/yy - mm/yy):
Position:
Reason for Leaving:
Start/End Dates (mm/yy - mm/yy):
Position:
Reason for Leaving:
Start/End Dates (mm/yy - mm/yy):
Position:
Reason for Leaving:
