Employee Application
Last 4 numbers of your SSN:
Salutation:
v
*First Name:
Middle Initial:
*Last Name:
Nickname:
Address:
* City:
* State:
v
* Zip:
*Home Phone:
Enter only numbers, area code first:
Cell Phone:
Enter only numbers, area code first:
Other Phone:
Enter only numbers, area code first:
Email:
In case of emergency, notify name:
Emergency Phone:
Enter only numbers, area code first:
Check if you are legally authorized to work in the United States:
* How did you hear of us:
v
 
* What position are you applying for:
Date available for work:
v
Minimum rate per hour:
Days you are available to work full-time:
 
What shifts you are available to work:
Preferred Shift:
What times are you available to work from:
   
To:
   
Checking the below boxes indicates YES:  
Do you have transportation:
Will you accept a same day assignment:
Will you accept a long term assignment:
Are you available part-time:
Are you available full-time:
Are you available temp-hire:
Are you available direct-hire:
 
City 
Yes 
Aliquippa
Allegheny County
Allison Park
Ambridge
Apollo
Beaver County
Beaver Falls
Belle Vernon
Blairsville
Blawnox
Bridgeville
Buffalo Grove, IL
Busline
Butler
Butler County
Cabot
Canonsburg
Carnegie
Cheswick
Chicora
Connellsville
Coraopolis
Crafton
Cranberry
Cranberry Twp.
Delmont
Derry
Ellwood City
Evans City
Export
Fombell
Ford City
Forest Hills
Freedom
Freeport
Gibsonia
Greensburg
Greentree
Greenville
Grove City
Harmony
Hopewell
Indiana
Irwin
Jeannette
Kittanning
Latrobe
Lawrence
Lawrence County
Leechburg
Leetsdale
Mars
McKees Rocks
Meadville
Mercer
Monaca
Monroeville
Moon Twp.
Mt. Pleasant
Mt.Prospect, IL
Murrysville
Natrona Heights
New Brighton
New Castle
New Kensington
New Stanton
North Hills
North Huntingdon
North Versailles
Northbrook, IL
Phoenix, AZ
Pittsburgh
Portersville
Richardson, TX
Robinson Township
Rochester
San Antonio, TX
Sarver
Saxonburg
Scottsdale, AZ
Sewickley
Slippery Rock
Smithton
Solon, OH
Somerset
South Hills
Southpointe
Tarentum
Uniontown
Vandergrift
Warrendale
West Middlesex
West Mifflin
Wexford
Wilkes Barre
Youngwood
Zelienople

Skill Title 
Yes 
[Collapse]Skill Set: 0001 MEDICAL OFFICE
 Co-Pays
 Insurance
 Patient Check In/Out
 Scheduling
 Customer Service
 Hippa Laws
 MS Access
 MS Excel
 MS Word
 MS Outlook
[Collapse]Skill Set: 0011 PHARMACY
 Hospital
 Mail Order
 Retail
 Pharmacist
 Pharmacy Technician
 Pharmacy Assistant
[Collapse]Skill Set: 0021 BILLING / COLLECTIONS
 CPT
 Prior Authorizations
 Billing
 Collections
 Medicare Part A
 Medicare Part B
 Medicare Part C
 Medicare Part D
 Ins. Verification
[Collapse]Skill Set: 0031 MEDICAL SUPPORT
 Call Center
 Enrollment
 Data Entry
 Data Analyst
 File Clerk
 Receptionist
 Administrative
[Collapse]Skill Set: 0041 OUTSTANDING ABILITY IN:
 Communications
 Fast Work Place
 Organization
 Work Independantly
 Team Player
 Analytical Thinking
[Collapse]Skill Set: 0051 EXPERIENCE/CERTIFICATES
 0-1 years
 2-3 years
 4-5 years
 6+ years
 Diploma
 Licensed
 Certified
 State
 National

Enter as much information as you can. More details will help us better serve you.
(Salary/Pay per hour: NOT REQUIRED in AL, CA, CO, CT, DE, HI, IL, MA, ME, NJ, NY, OR, VT, WA)

Previous Employment #1

Dates of employment: From: To:
v
v
Name of employer:
Address:
City, State, Zip:
v
Phone:
Supervisor:
Job Position:
Pay per hour:
Reason for leaving:

Previous Employment #2

Dates of employment: From: To:
v
v
Name of employer:
Address:
City, State, Zip:
v
Phone:
Supervisor:
Job Position:
Pay per hour:
Reason for leaving:
   

Previous Employment #3

Dates of employment: From: To:
v
v
Name of employer:
Address:
City, State, Zip:
v
Phone:
Supervisor:
Job Position:
Pay per hour:
Reason for leaving:

Previous Employment #4

Dates of employment: From: To:
v
v
Name of employer:
Address:
City, State, Zip:
v
Phone:
Supervisor:
Job Position:
Pay per hour:
Reason for leaving:
 

Temporary Employment

FIRM # 1

FIRM # 2

Firm name:
Address:
City, State, Zip:
v
Please list at which clients you were placed, job category, and to whom you reported. Please share your thoughts on the agency and your assignment:
Firm name:
Address:
City, State, Zip:
v
Please list at which clients you were placed, job category, and to whom you reported. Please share your thoughts on the agency and your assignment:
 

High School Education

Name of high school:
High school degree:
High school diploma/certificate:

Business or Other Education

Name of school/program:
School/program degree:
School/program diploma/certificate:

College Education

Name of college:
College degree:
College diploma/certificate:
               
      I certify that the information on this application is true and factual
  


Submit Your Application


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