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(ear, nose, throat)
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Clinical Job Application
Apply Online
Click here
or scroll down to complete our job application online.
Mail
Download the application PDF file
Print and complete
Mail the completed application to
our office
.
Print/Scan/Email
Download the application PDF file
Print and complete
Scan
Email the completed PDF to
Kerri Parnell
Print/Fax
Download the application PDF file
Print and complete
Fax the completed form to 870-932-6435
Step 1 of 7 - Position Information
Position applied for
Who referred you to this Center?
Minimum Salary Requirement
Status Preferred:
Full-time
Part-time
PRN
Shift Preference:
First
Second
Third
Fourth
Application History
Have you ever worked at this Center before?
Yes
No
When?
Position:
Have you ever applied at this Center before?
Yes
No
When?
Please explain:
Step 2 of 7 - General Information
First Name
Middle Initial
Last Name
Residence Address:
City:
State:
Zip:
Telephone:
How long have you lived here:
Previous Address:
City:
State:
Zip:
Telephone:
How long did you live here:
Citizenship Status:
Legal Citizen
Resident Alien
Student Visa
Visitor Visa
Other
If you are not a citizen, what is your visa #:
What is your visa expiration date?
Step 3 of 7 - Professional Registration Or Licensure
1) Type:
State:
Renewal Date:
Expiration Date:
2) Type:
State:
Renewal Date:
Expiration Date:
3) Type:
State:
Renewal Date:
Expiration Date:
Have you ever been in the U.S. armed forces?
Yes
No
Length of military service? From:
To:
Have you ever been bonded?
Yes
No
Have you ever been convicted of a felony?
Yes
No
If yes, what was the felony?
When?
What was the outcome?
Have you ever been terminated from or asked to resign from a position?
If yes, explain:
Person to be contacted in case of emergency:
Name:
Phone Number:
Step 4 of 7 - References
1)Name and Address:
Telephone:
2)Name and Address:
Telephone:
3)Name and Address:
Telephone:
4)Name and Address:
Telephone:
5)Name and Address:
Telephone:
6)Name and Address:
Telephone:
Step 5 of 7 - Employment History
1)Name of Employer:
Street:
City:
State:
Zip:
Date from:
to:
Position:
Position(s) Held:
Explain your duties, responsibilities and number of people supervised, if any:
Why did you leave?
Name of Supervisor:
Phone # of Supervisor:
May we contact?
Yes
No
2)Name of Employer:
Street:
City:
State:
Zip:
Date from:
to:
Position:
Position(s) Held:
Explain your duties, responsibilities and number of people supervised, if any:
Why did you leave?
Name of Supervisor:
Phone # of Supervisor:
May we contact?
Yes
No
Step 6 of 7 - Education
High School and/or G.E.D.:
Name and Location:
Highest Grade Completed:
Grade Average:
Did you graduate?
Yes
No
If yes, what was your major study?
Last year of study:
College:
Name and Location:
Highest Year Completed:
Grade Average:
Did you graduate?
Yes
No
If yes, what was your degree and major?
Last year of study:
Trade or Business School:
Name and Location:
How long:
Grade Average:
Did you graduate?
Yes
No
If yes, what was your major?
Last year of study:
List other training you have had:
Extracurricular Activities, Offices held:
Academic honors or special recognition:
Current Memberships in Professional Organizations:
Past Memberships in Professional Organizations:
Sports, Hobbies and other interests:
Step 7 of 7 - Clerical Only
Have you had experience in the following?
Accounting
Yes
No
Length of Time?
Billing and Collecting
Yes
No
Length of Time?
Medical Records
Yes
No
Length of Time?
Managed care
Yes
No
Length of Time?
Managed care contracting
Yes
No
Length of Time?
Computers
Types:
Yes
No
Length of Time?
Dictation
Yes
No
Length of Time?
Typing
Average words per minute:
Yes
No
Length of Time?
Other
Yes
No
Length of Time?
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