ࡱ> '` &bjbjLULU |.?.?"4"""h#$\7,z$z$$$$%%%*7,7,7,7,7,7,7$8h?;P7-%%--P7$$;e7000-^8$$*70-*700:5,5$n$ 4`0".>5 *7{707H5R<.<5<5% 'v0K),w*+%%%P7P7/^%%%7----DR"dR"   APPLICATION FOR EMPLOYMENT We appreciate your interest in Wake Forest Baptist Health - Community Physicians. Please be assured that each application receives careful consideration. We ask that you not call the office to check on the status of your application, this slows the application process. Should our needs meet your qualifications, you will be personally contacted to come in for an interview. If your qualifications do not meet our needs at this time, your application will be held in our active files for one year. PLEASE ANSWER ALL QUESTIONS COMPLETELY. PLEASE PRINT USING A BALL POINT PEN. Social Security Number: ______-_____-_____ Name: First MI Last Address: City: State: ZIP Code: Home Phone: ( ) - Business / Cell Phone: ( ) - Emergency Contact Name: Phone: ( ) - POSITION APPLIED FOR (must be a posted position): Years of Experience: Salary Expected: $ Education Completed: ( High School Equivalent ( Four-Year College Degree ( Some College ( Some Graduate Work ( Two-year College Degree ( Graduate Degree Are you legally eligible for employment in the USA? ( Yes ( No If hired, you are required to submit proof of your eligibility to work in the USA. If you are under 18 years of age, can you provide required proof of eligibility to work? ( Yes ( No Will you require any accommodations to further participate in the application process? ( Yes ( No Have you ever been convicted of a crime other than a minor traffic violation? ( Yes ( No Have you ever paid for a fine or restitution in the Office of the Clerk of Courts to resolve a violation of the law? ( Yes ( No If you answered yes to questions 4 or 5 above, please explain. (Yes does not automatically disqualify you from employment.) By whom or what source were you referred to Community Physicians? ( A Community Physician Employee ( Employment Security Commission ( Walk-In ( A Medical Center Employee ( College/University ( Other ( Newspaper Ad ( Job Fair (Specify) I prefer: ( Full-Time employment ( Part-Time employment ( Either Date of Availability: _______/_______/_______ Hours Available for Work: to Days Available for Work: EDUCATION RECORD High School: Address: Number of years completed: __________ Did you graduate? ( Yes ( No Last Year Attended: College or Technical School: Address: Number of years completed: __________ Did you graduate? ( Yes ( No Last Year Attended: Degree: Major: Minor: GPA: Other: Address: Number of years completed: __________ Did you graduate? ( Yes ( No Last Year Attended: Degree: Major: Minor: GPA: PROFESSIONAL / TECHNICAL LICENSURE License Name Date Issued ___/___/___ State ____ License # Exp date___/___/___ License Name Date Issued ___/___/___ State ____ License # Exp date___/___/___ License Name Date Issued ___/___/___ State ____ License # Exp date___/___/___ Have you ever had a professional or technical license revoked? ( Yes ( No If yes, please explain: SKILLS: Coding: ( Yes ( No Accounting: ( Yes ( No Multiline telephone: ( Yes ( No Insurance Billing: ( Yes ( No Medical Terminology: ( Yes ( No Computer Skills / Programs: ( Yes ( No (Specify): Foreign Languages: ( Yes ( No (Specify): Other relevant skills (Specify): An Affiliate of Wake Forest Baptist Health Equal Opportunity Employer EMPLOYMENT RECORD: (List most recent positions first. Fill in employers name, address & telephone number.) Firm Name: Beginning Salary: Address: Ending Salary: Job Title: Employed from: to Describe your duties: Supervisors Name: Phone: ( ) - Reason for Leaving: May we contact: ( Yes ( No Firm Name: Beginning Salary: Address: Ending Salary: Job Title: Employed from: to Describe your duties: Supervisors Name: Phone: ( ) - Reason for Leaving: May we contact: ( Yes ( No Firm Name: Beginning Salary: Address: Ending Salary: Job Title: Employed from: to Describe your duties: Supervisors Name: Phone: ( ) - Reason for Leaving: May we contact: ( Yes ( No If you have more than three previous employers, please include on an additional sheet. ADDITIONAL INFORMATION: (Please provide any volunteer work or other information you think may be helpful.) Have you ever been employed by Community Physicians?: ( Yes ( No If yes, dates employed: _______/_______/_______ until _______/_______/_______ Location: Position (Title): Does Community Physicians employ any of your relatives?: ( Yes ( No If yes, please indicate: Name: Relationship: Location: REFERENCES: (Please list three references, not relatives or former employers, who are acquainted with your work history.) Name Address Occupation Phone WAKE FOREST BAPTIST HEALTH COMMUNITY PHYSICIANS I understand that if I am offered a position by Wake Forest Baptist Health - Community Physicians my employment will be conditional subject to verification of my statements, receipt of satisfactory references, successful completion of a pre-employment drug screening test, and a criminal background check. I understand that if my position is of a financial nature, that I may be asked to authorize Community Physicians to complete a Consumer Report (Credit Background Check.) I further understand that any false statement on this application may result in either rejection of the application or dismissal. I authorize Community Physicians to obtain personal and ability references from personal, educational and previous employment sources and hereby release Community Physicians and former employers from all liability for issuing such information. I understand that I will be an employee at will without a fixed term of employment, and that my employment and compensation can be terminated with or without cause, and with or without notice, at any time by either Community Physicians or myself, unless there is a written contract stating otherwise. I hereby acknowledge that I have read and understand the above statements and have not misrepresented the facts on this job application. Signature of Applicant: ______________________________________________ Date: SUBMIT APPLICATION TO: WAKE FOREST BAPTIST HEALTH COMMUNITY PHYSICIANS RECRUITMENT 1920 West First Street Piedmont Plaza 1, 4th Floor Winston-Salem, NC 27104 Fax: (336) 716-5656 www.wakehealth.edu/cp     PAGE  07/11  HIJKLXfgh] ^ _ ` g u żyk_SJAhcC5CJaJh,<5CJaJhsSh5CJ aJ hA&hA&6CJaJhA&hJY56CJaJhs56CJaJhA&hA&56CJaJhhA&6CJ aJ h5CJaJhh[h5CJaJhta5CJaJh5CJaJh5CJ aJ hcC5CJaJh$.5CJaJ&jhshs5>*CJU\aJhh[hcCh$.JKLgh^ _ `  4 5 h i = $a$gd"f$ !&d$P$a$gd$. &d$P$gdA& $ a$gd$. gdm8$a$gd&&&u v   ƻ}qf]Q]hsSh 2e6CJaJhsS6CJaJhsShLCJaJhsShh[>*CJaJhsS>*CJaJhsSh>*CJaJhsSCJaJhsSh 2eCJaJhsShCJaJhsShh[CJaJhsShh[CJaJhh[hh[5CJaJh$NS5CJaJh,<5CJaJhrD*5CJaJhcC5CJaJh 5CJaJ     $ & 3 4 9 ; C H M O U Z _ b d e f g h i u ŹŹŹŢŹōłłŢwkkkhsShn>*CJaJhsShnCJaJhsSh$.CJaJhsSh>*CJaJhsS>*CJaJhsSh 2eCJaJhsShh[>*CJaJhsSh>*CJaJhsShCJaJhsShh[CJaJhsShh[6CJaJhsSh 2e6CJaJhsShL6CJaJ*     9 : < = > ? 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