Gwen's Advanced Care, LLC
(602) 595-5707
[email protected]
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Office Manager Employment Application
Office Manager Employment Application
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– Personal Information
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Welcome:
The Office Manager is responsible for the efficient and effective operation of our main office, including daily operations involving personnel management and performance, patient throughout, provider relations and scheduling, department budget preparation and the overall management of assigned practice operations with a focus to maximize provider/staff productivity. The Office Manager will be involved in strategic planning, program development, continuous quality improvement.
PERSONAL INFORMATION
Name:
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First
Middle
Last
Current Address:
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Street Address
City
State / Province / Region
ZIP / Postal Code
Home Phone:
Cell Phone:
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This field is hidden when viewing the form
Alternate Phone:
Email:
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Enter Email
Confirm Email
Date of Birth:
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MM slash DD slash YYYY
Are you a U.S. Citizen?
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Yes
No
What language do you speak?
*
Check all that apply
English
Spanish
Other
Other languages:
Have you ever been charged/convicted of a felony?
*
(Convictions will not necessarily disqualify an applicant for employment.)
Yes
No
Please Describe:
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AVAILABILITY:
Due to the nature of our business, no guarantee can be made of the scheduled amount of hours you are scheduled per week. The scheduled hours are based on the members’ needs.
What date are you available to begin work?
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MM slash DD slash YYYY
How many hours per week are wanting to work?
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Sunday
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Sunday
Start Time
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Monday
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Tuesday
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Tuesday
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Wednesday
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End Time
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Thursday
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Friday
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Saturday
*
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Have you ever been employed with Gwen's Advance Care?
Yes
No
If yes, when?
Have you ever been employed with Arizona Department of Economic Security (DES), Division of Developmental Disabilities (DDD)?
Yes
No
If yes, when?
How did you hear about us? (i.e., family, friends, website, Internet, advertisement)
EDUCATION:
Position Minimum Requires a High School Diploma or GED
Do you have a High School Diploma or GED?
*
High School Diploma
GED
High School
*
Name
City
*
City
State
*
State
Year Graduated
*
Year Graduated
Trade/Tech School
Name
City
City
State
State
Trade
Trade
Certificate Received
Certificate Received
Year Graduated
Year Graduated
College/University
Name
City
City
State
State
Major
Major
Degree Received
Degree Received
Year Graduated
Year Graduated
List any special skills or training that you feel would help you in the position that you are applying for (billing, human resources,office management, etc.)
WORK HISTORY
Please fill out all questions in this section. Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are essential.
Previous Work Experience?
*
Yes
No
Resume Upload
Max. file size: 100 MB.
Company #1
*
Name
Are you currently working for this employer?
*
Are you currently working for this employer?
Yes
No
City
*
City
State
*
State
Phone Number
*
Phone Number
Supervisor's Name
*
Supervisor’s Name
May we contact?
*
May we contact?
Yes
No
Employment Start
*
Employment Start
MM slash DD slash YYYY
Employment End
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Employment End
MM slash DD slash YYYY
Job Title
*
Job Title
Salary
*
Salary
Duties
*
Duties
Reason for leaving
*
Reason for leaving
Company #2
Name
Are you currently working for this employer?
Are you currently working for this employer?
Yes
No
City
City
State
State
Phone Number
Phone Number
Supervisor's Name
Supervisor’s Name
May we contact?
May we contact?
Yes
No
Employment Start
Employment Start
MM slash DD slash YYYY
Employment End
Employment End
MM slash DD slash YYYY
Job Title
Job Title
Salary
Salary
Duties
Duties
Reason for leaving
Reason for leaving
Company #3
Name
Are you currently working for this employer?
Are you currently working for this employer?
Yes
No
City
City
State
State
Phone Number
Phone Number
Supervisor's Name
Supervisor’s Name
May we contact?
May we contact?
Yes
No
Employment Start
Employment Start
MM slash DD slash YYYY
Employment End
Employment End
MM slash DD slash YYYY
Job Title
Job Title
Salary
Salary
Duties
Duties
Reason for leaving
Reason for leaving
List any experience that you feel would help you in the position that you are applying for (office management, organizations/teams, etc.)
REFERENCES:
(Please list three professional references not related to you. If you don’t have three professional references, then list personal, unrelated references.)
Reference Name #1
*
First
Last
Relationship
*
Relationship
Years Known
*
Years Known
Phone
*
Phone
Email
Email
Reference Name #2
*
First
Last
Relationship
*
Relationship
Years Known
*
Years Known
Phone
*
Phone
Email
Email
Reference Name #3
*
First
Last
Relationship
*
Relationship
Years Known
*
Years Known
Phone
*
Phone
Email
Email
CERTIFICATION AND RELEASE:
I certify that I have read and understand this application form and that the answers and statements given by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts in this application may result in the rejection of my application or discharge at any time during my employment. I authorize the company and its agents, including consumer-reporting bureaus to verify any of this information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I release this company from any liability, which might result from making such investigations. I also understand that the use of illegal substances is prohibited during employment. I am willing to submit to drug testing to detect the use of illegal substances prior to, and during employment. I understand that this application is not a contract of employment. My employment is contingent upon confirmation of credentials and successful completion of drug test and/or criminal background check and all company guidelines. I also understand that if hired, regardless of any oral presentations to the contrary, the employment relationship between Gwen’s Advance Care, LLC, and myself is terminable as at-will so that both the company and I remain free to choose to end our work relationship at any time for any or for no reason. Any changes in this employment relationship must be made in writing. I also understand that due to the nature of the business, no amount of work can be guaranteed.
My signature below acknowledges that I have read, understand, and agree to the above disclosure.
*
Agree
Electronic Signature
*
Date
*
MM slash DD slash YYYY