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Which position are you applying for?
Medical Assistant
Front Desk
HIV Tester
Case Manager
Email
*
Name
*
First
Last
Address
*
City
*
State
*
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ZIP Code
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Are you 18 years old or older?
*
Yes
No
Are you either a U.S. citizen or an alien authorized to work in the U.S.?
*
Yes
No
Have you ever worked or attended school under another name? If so, under what name?
Desired Position
Location Applying For
Fort Pierce (Main Office)
Fort Pierce Primary Care
Port St. Lucie Primary Care
Tampa
Wilton Manor
West Palm Beach
Orlando
Miami
Miami Beach
Key West
Have you previously worked for this company?
Reason for leaving
Former supervisor(s) at this company
How did you learn about this opening?
High School Attended
Graduated?
Yes
No
College/ University Attended
Graduated?
Yes
No
College/ University Course of Study
Postgraduate School Attended
Graduated?
Yes
No
Postgraduate School Course of Study
Other Education, Training, or Certifications Held
Branch of Service
Date Served
Rank at Discharge
Military Education and Training
Prior Employer
Prior Employer Address
Prior Employer City
Prior Employer State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Prior Employer ZIP Code
How long where you with this employer?
Position Held
Reason for Leaving
Manager's Name, Title, and Contact Phone Number
Description of Duty
Starting Salary/ Hourly Rate
Final Salary/ Hourly Rate
Second Prior Employer
Second Prior Employer Address
Second Prior Employer City
Second Prior Employer State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Second Prior Employer ZIP Code
How long where you with this second employer?
Second Position Held
Reason for Leaving Second Employer
Second Manager's Name, Title, and Contact Phone Number
Second Description of Duty
Second Starting Salary/ Hourly Rate
Second Final Salary/ Hourly Rate
Third Prior Employer
Third Prior Employer Address
Third Prior Employer City
Third Prior Employer State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Third Prior Employer ZIP Code
How long where you with this third employer?
Third Position Held
Reason for Leaving Third Employer
Third Description of Duty
Third Manager's Name, Title, and Contact Phone Number
Third Starting Salary/ Hourly Rate
Third Final Salary/ Hourly Rate
Did you work under any other name during the above employment? If yes, please give the name used?
Have you ever been arrested? If yes, please provide details and current status
Applicant Signature
*
First
Last
Date of Application
*
Do you accept the conditions of the Applicant Waiver?
*
Yes
No
APPLICANT WAIVER – I hereby certify that the information hereunder is correct to the best of my knowledge and understand that falsification of this information is grounds for a refusal to hire or, if hired, dismissal. I hereby authorize any of the persons or organizations listed in my application to give all information concerning my previous employment, education, or any other information they might have, personal or otherwise, with regard to any of the subjects covered by this application, and release all such parties from all liability that may result from furnishing such information to you. I authorize you to request and receive such information. In consideration for my employment and my being considered for employment by your company, I agree to adhere to the rules and regulations of the company and hereby acknowledge that these rules and regulations may be changed by your company at any time, at the company’s sole option and without any prior notice. In addition, I acknowledge that my employment may be terminated, and any offer of employment, if such is made, maybe withdrawn, with or without prior notice, at any time, at the option of either the company or myself. I understand that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to assure or make some other personnel move, either prior to commencement of employment or after I have become employed, or to assure any benefits or terms and conditions of employment, or to make any agreement, that is contrary to the foregoing. I hereby acknowledge that I have been advised that this application will remain active for no more than 90 days from the date it was signed.
Do you accept the conditions of the Employment Application Disclaimer and Acknowledgement?
*
Yes
No
EMPLOYMENT APPLICATION DISCLAIMER AND ACKNOWLEDGEMENT – I certify that the information contained in this application is correct to the best of my knowledge. I understand that to falsify information is grounds for refusing to hire me, or for discharge should I be hired. I authorize any person, organization, or company listed on this application to furnish you with any and all information concerning my previous employment, education, and qualifications for employment. I also authorize you to request and receive such information. In consideration for my employment, I agree to abide by the rules and regulations of the company, which rules may be changed, withdrawn, added, or interpreted at any time, at the company’s sole option, and without prior notice to me. I also acknowledge that my employment may be terminated, or any offer or acceptance of employment withdrawn, at any time, with or without cause, and with or without prior notice at the option of the company or myself.
Is the information you have provided accurate?
*
Yes
No
Submit
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