EMPLOYMENT APPLICATION
[pic] SCRIBE EMPLOYMENT APPLICATION
|Name: Last, First |Today’s Date: | |
| | | |
|Address: Street City State Zip |
| |
|Contact info: Home Phone Cell Phone |E-mail |
| | |
|Education: |School name, location, year graduated |No. of years |Course of study |GPA |
| | |completed | | |
|High School | | | | |
|College | | | | |
| | | | | |
|Post Graduate School: |
| |
|Do you plan to apply to a graduate school program (medical school, PA school, etc.)? If so, when (month/year) do you hope to start classes? |
| |
| |
|When would you like to start working as a scribe? |
| |
| |
|WORK EXPERIENCE: You must complete this section even if attaching a resume. Start with your current or most recent position, and account for all periods |
|of employment (including full-time, part-time, and temporary) for the previous five years. Use additional pages if necessary. |
|1 Company: |Fm: Mo / yr To: Mo / yr |Starting salary: |
| | | |
| | |Final salary: |
|Address: |May we contact your supervisor? Yes| Full-time Part-time |
| |No | |
|Position: |Supervisor’s name: |Reason for leaving: |
| | | |
| | | |
| |Phone number: | |
|Duties: | |EXPLANATION: |
| | | |
| | | |
|2 Company: |Fm: Mo / yr To: Mo / yr |Starting salary: |
| | | |
| | |Final salary: |
|Address: |May we contact your supervisor? Yes| Full-time Part-time |
| |No | |
|Position: |Supervisor’s name: |Reason for leaving: |
| | | |
| | | |
| |Phone number: | |
|Duties: | |EXPLANATION: |
| | | |
| | | |
|3 Company: |Fm: Mo / yr To: Mo / yr |Starting salary: |
| | | |
| | |Final salary: |
|Address: |May we contact your supervisor? Yes| Full-time Part-time |
| |No | |
|Position: |Supervisor’s name: |Reason for leaving: |
| | | |
| | | |
| |Phone number: | |
|Duties: | |EXPLANATION: |
| | | |
| | | |
|References |
|#1 |
|Name: |
| |
|Address: |
|Phone Number: |
|Relationship: |
| |
| |
|Permission to Contact: |
|#2 |
|Name: |
| |
|Address: |
|Phone Number: |
|Relationship: |
| |
| |
|Permission to Contact: |
|#3 |
|Name: |
| |
|Address: |
|Phone Number: |
|Relationship: |
| |
| |
|Permission to Contact: |
|Questions: |
|Why do you want to be a scribe? |
|What qualities and experiences do you possess that make you a competitive candidate? |
|What previous experience do you have in the medical field? |
|Are you comfortable using computers? What is your average typing speed (words per minute)? |
|How many hours per week would you like to work? |
|Do you have schedule restrictions? |
|If you are not chosen in this round, would you like to be considered in the future for a position as a scribe? |
| |
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