HomeEspanolWomen`s HealthMenDirectionsGMC News & Press

Search

 

 
Application Form

GREELEY MEDICAL CLINIC, P.C

An Equal Opportunity Employer
We do not discriminate on the basis of race, color, religion, national origin, sex, age, disability, or any other status protected by law or regulation. It is our intention that all qualified applicants are given equal opportunity and that selection decisions be based on job-related factors.
Application for Employment
Use the tab key to move from field to field. Use the enter key or the submit button to submit your completed application.
Personal Information
Name: First: Middle: Last:
Present Address: Street: City: State: Zip:
Check it, if your Permanent Address is same.
Permanent Address: Street: City: State: Zip:
Home Phone: Message Phone:
Email

Employment Desired:
1st Choice:
Desired Wage: $ per
2nd Choice:
Desired Wage: $ per
Date available for work:
Are you willing to work overtime as required? Yes No
You will Work: Full time Part time PRN
If Part-time or PRN, specify hours or days:
Do you have any commitments to another employer that might affect your employment with us? Yes No
Have you ever applied to this company before? Yes No
If Yes, When?
Have you worked for this company? Yes No
If Yes, Position: Dept.: Dates:
Have you ever been discharged from employment or asked to resign? Yes No
If so, please explain:
Referred by:
Employee (name):
Newspaper (Which Paper?):
Internet Advertisement (name):
Walk-in
Other:

General Information:
Can you, after employment, submit verification of your legal right to work in the United States? Yes No
Can you perform the essential functions of the job with or without accommodations? Yes No

Education
Name and Location of School Last Year Completed Subjects Studied and Degree(s) Received Did you Graduate?
High School 1 2 3 4 Yes No
College 1 2 3 4 Yes No
Trade, Business, Correspondence or Graduate School 1 2 3 4 Yes No
Subjects of Specific Study or Research Work Applicable to Specific Position Applied for:

Work Experience(List your last three employers, starting with present or most recent)
1st Employer
Address:
(Street, City, State, Zip Code)
Job Title
Job Responsibilities
Dates From: To
Starting Pay: Ending Pay:
Reason for leaving:
May we contact this employer for a reference? Yes No
If no, why not?
Phone

2nd Employer
Address:
(Street, City, State, Zip Code)
Job Title
Job Responsibilities
Dates From: To
Starting Pay: Ending Pay:
Reason for leaving:
May we contact this employer for a reference? Yes No
If no, why not?
Phone

3rd Employer
Address:
(Street, City, State, Zip Code)
Job Title
Job Responsibilities
Dates From: To
Starting Pay: Ending Pay:
Reason for leaving:
May we contact this employer for a reference? Yes No
If no, why not?
Phone

Experience and Skills: Check any of the following in which you have a working knowledge:
Typing W.P.M.: Yes No Filing Yes No
CPT coding Yes No High Volume Phones Yes No
Know medical terminology Yes No Computer billing Yes No
Account collections Yes No Insurance processing Yes No
Scheduling appointments on computer Yes No Bilingual Yes No
Set up and assist with minor surgery Yes No Blood Draws Yes No
Scheduling test with outside facilities Yes No Give injections Yes No
Preparing patients for surgery Yes No Recovering patients from surgery Yes No
Urinalysis by dipstick Yes No Perform venipunctures Yes No
Cash Handling/Balancing Yes No Other Skills
Professional Licenses/Certifications:
Type State Expiration Date Registration Number
References: List three individuals who have knowledge of your work ethic, experience, and ability.
(Do not include individuals listed in employment history section or individuals that are related to you)
Name Address Business Phone Occupation
Criminal Record Information
Have you been convicted of any law violations within the last seven years? Include any plea of “guilty” or “ no contest”. (Exclude minor traffic violations). Yes No
If yes, please describe below:(A conviction record will not necessarily disqualify an applicant for employment)
Driving Positions Only:
Do you have a valid driver’s license? Yes No
In the past three (3) years, has any license, permit, or privilege to operate a motor vehicle ever been suspended or revoked? Yes No
Applicant’s Statement / Affidavit, Consent and Release:
PLEASE READ EACH STATEMENT CAREFULLY BEFORE SUBMITTING THE FORM

I certify that my responses to the above questions are true, and I understand that any misrepresentation or omission of facts may disqualify me from employment or constitute grounds for termination. I authorize Greeley Medical Clinic to investigate all statements and references contained in my application/resume. I also authorize, whether listed or not, any person, school, current employer, past employers, and organizations to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements.

I understand I may be required to successfully pass a drug screening examination. I hereby consent to a pre-employment drug screen as a condition of employment.

I understand that Greeley Medical Clinic follows an "employment at will" policy, which means that either Greeley Medical Clinic or I am free to terminate employment with or without cause and with or without notice, at any time. I understand that the terms and conditions of my employment may be changed, with or without notice, by Greeley Medical Clinic. I understand that no representative of Greeley Medical Clinic, other than an officer, has the authority to enter into any contract or agreement and then only if the commitment is a signed written document.



Alternatively, you can Download an Application for Employment

 

 

 

Español | Women's Health | Men's Health | Directions | GMC News & Press
---------------------------------------------------------------------------------------------------------------------------------------------
About GMC | Medical Specialities | Physicians Directory | GMC Directions | Audiology | CHAMPS | Diagnostic Imaging | Exercise Services | Lab | Pharmacy | Physical Therapy | GMC Locations | Careers
Admission Info | Payment Info | GMC News & Press | Helpful Links | Contact Us | Privacy Policy | Sitemap
 

© 2005 Greeley Medical Clinic