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Office Manager Employment Application

Office Manager Employment Application

Step 1 of 6 – 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

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  • MM slash DD slash YYYY
  • Check all that apply
  • (Convictions will not necessarily disqualify an applicant for employment.)
  • 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.
  • MM slash DD slash YYYY








  • EDUCATION:

    Position Minimum Requires a High School Diploma or GED
  • Name
  • City
  • State
  • Year Graduated
  • Name
  • City
  • State
  • Trade
  • Certificate Received
  • Year Graduated
  • Name
  • City
  • State
  • Major
  • Degree Received
  • Year Graduated
  • 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.
  • Max. file size: 1 GB.
  • Name
  • Are you currently working for this employer?
  • City
  • State
  • Phone Number
  • Supervisor’s Name
  • May we contact?
  • Employment Start
    MM slash DD slash YYYY
  • Employment End
    MM slash DD slash YYYY
  • Job Title
  • Salary
  • Duties
  • Reason for leaving
  • Name
  • Are you currently working for this employer?
  • City
  • State
  • Phone Number
  • Supervisor’s Name
  • May we contact?
  • Employment Start
    MM slash DD slash YYYY
  • Employment End
    MM slash DD slash YYYY
  • Job Title
  • Salary
  • Duties
  • Reason for leaving
  • Name
  • Are you currently working for this employer?
  • City
  • State
  • Phone Number
  • Supervisor’s Name
  • May we contact?
  • Employment Start
    MM slash DD slash YYYY
  • Employment End
    MM slash DD slash YYYY
  • Job Title
  • Salary
  • Duties
  • Reason for leaving
  • REFERENCES:

    (Please list three professional references not related to you. If you don’t have three professional references, then list personal, unrelated references.)
  • Relationship
  • Years Known
  • Phone
  • Email
  • Relationship
  • Years Known
  • Phone
  • Email
  • Relationship
  • Years Known
  • Phone
  • 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.
  • MM slash DD slash YYYY
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