Medical Associates Careers - Apply for Ancillary Charge Specialist

First Name - (legal/given name)*

Preferred First Name - if different than legal/given name

Middle Initial*

Last Name*

Email*

Cell Phone*

Home/Primary Phone*

Address (cannot be PO Box)*

City*

State*

Zip Code*

To be considered for the position, please complete the following information to the best of your ability.

General Application Information

Are you at least 18 years of age or older?* Yes No

Do you have the legal right to work in the United States?* Yes No

Do you now or in the future require sponsorship for employment visa status to work in the United States? (example: H-1B or J-1 visa status)* Yes No

Please select how you heard about this position.

Candidate Referral Source*

Were you encouraged to apply at Medical Associates by a current Medical Associates employee?* Yes No

If yes, please list the name of the employee who was most influential in your decision to apply (list only one).

Have you ever been employed by Medical Associates in the past?* Yes No

If yes, please provide job title, department, and dates of employment (month/year):

Why did you leave Medical Associates?

Check the following options that you would consider:* Full-time (30 hours or more per week) Part-time (less than 30 hours per week) Full-time or part-time

What is your wage (hourly/salary) requirement?

What is your current wage (hourly/salary)?

Date available to start?*

If you have any scheduled commitments that would affect your availability to work, please include here:

INTERNAL APPLICANTS ONLY

Have you been in your current position for at least 6 months or longer? Yes No

Did you receive a commendable rating or higher on your last employee review? Yes No NA - haven't received an annual review yet

Is your manager aware of your interest in applying for a new position? (If not, please inform him/her as they are contacted for performance feedback as part of the candidate selection process.) Yes No

Education, Certification, and Professional Licenses

Please select the highest educational degree you have earned.*

College Education

Name and location of College

Subjects studied and degree(s) received

Last year completed

Did you graduate?

Graduate, Trade, or Business School

Name and location of Graduate, Trade or Business School

Subjects studied and degree(s) received

Last year completed

Did you graduate?

Professional License or Certification

Please list any professional certifications or licenses you have earned (including certification number, and month/year that license will expire)

Current or Most Recent Employer

Employer Name, Address, City and State*

Dates of Employment (month/year - month/year)*

Job Title and Brief Description of Duties*

Last Salary or Hourly Wage

Why did you leave this job? If still employed, enter "still employed"*

Supervisor Name, Title, Email and Phone Number*

May we contact this employer?* Yes No

Employer Name, Address, City and State

Dates of Employment (month/year-month/year)

Job Title and Brief Description of Duties

Last Salary or Hourly Wage

Why did you leave this job? If still employed, enter "still employed"

Supervisor Name, Title, Email and Phone Number

May we contact this employer? Yes No

Employer Name, Address, City and State

Date of Employment (month/year)

Job Title and Brief Description of Duties

Last Salary or Hourly Wage

Why did you leave this job? If still employed, enter "still employed"

Supervisor Name, Title, Email and Phone Number

May we contact this employer? Yes No

Employer Name, Address, City and State

Date of Employment (month/year)

Job Title and Brief Description of Duties

Last Salary or Hourly Wage

Why did you leave this job? If still employed, enter "still employed"

Supervisor Name, Title, Email and Phone Number

May we contact this employer? Yes No

Criminal Record Information

Have you ever been convicted for any felony or misdemeanor which may include intoxication driving charges, traffic violations, etc ?* Yes No

If yes, please briefly explain the type of offense, date, location of occurrence and disposition.

Professional License/Certification

Have you ever had your professional license/certification suspended/revoked (voluntarily or involuntarily) and/or disciplinary actions against your professional license/certification?* Yes No

If yes, please provide an explanation and dates of occurrence(s).

Other Relevant Information

Please omit all information that would indicate age, sex, sexual orientation, race, religion, color, national origin, protected veteran status or disability.

You may provide any other information you think would be helpful to us in considering you for employment, such as why you are interested in this position, additional skills/training (excel, electronic medical records,etc.)

Job Description Acknowledgement

By selecting Yes, I confirm that I fully understand all essential job functions as outlined in the job description; including the physical requirements and that I am able to perform those essential job functions with or without accommodations. I also understand that my ability to perform those essential job functions, including the physical requirements will be evaluated at a pre-employment physical exam if hired. If you selected No, please contact Human Resources.

I have reviewed the job description and physical requirements for this position. I understand that duties, hours, wages, benefits, and reporting relationships are subject to change at Medical Associates’ discretion and that employment is at-will.* Yes No

If you are offered a position at Medical Associates, offers are contingent upon successful completion of a background check and a pre-employment physical and drug screening test. Please review the statements below and indicate your understanding and agreement: 1. I authorize Medical Associates to obtain and use a consumer and/or investigative consumer report for employment purposes. That may include information as to my character, general reputation, personal characteristics, mode of living, work experience and performance, along with reasons for termination of past employment. The report may also contain records check of driving, criminal, credit, education, degrees, professional licenses and/or certification records depending on the position. 2. I understand that if hired, I will be required to complete a pre-employment physical and drug screening test, including the collection, and testing of a blood and/or urine sample and my offer may be rescinded if I fail a drug screen. 3. I affirm that the information provided on this application (and accompanying résumé, if any) is true and complete to the best of your knowledge, and acknowledge that falsified information or significant omissions may disqualify me.

By clicking "Yes" you are signifying agreement with the above statements.* Yes No

Ancillary Charge Specialist

Add Resume(optional)

Personal Information

General Application Information

INTERNAL APPLICANTS ONLY

Education, Certification, and Professional Licenses

Current or Most Recent Employer

Criminal Record Information

Professional License/Certification

Other Relevant Information

Job Description Acknowledgement

Social Profile (optional)

Additional Files (optional)