Personal Assistant Employment Application Step 1 of 6 - Personal Information 16% 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 INFORMATIONName:* First Middle Last Current Address:* Street Address City State / Province / Region ZIP / Postal Code Home Phone:Cell Phone:*This field is hidden when viewing the formAlternate Phone:Email:* Enter Email Confirm Email Date of Birth:* MM slash DD slash YYYY Are you a U.S. Citizen?* 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:* 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?* MM slash DD slash YYYY How many hours per week are wanting to work?*Sunday* Sunday Start Time*AnyNone12:00 am1:00 am2:00 am3:00 am4:00 am5:00 am6:00 am7:00 am8:00 am9:00 am10:00 am11:00 am12:00 pm1:00 pm2:00 pm3:00 pm4:00 pm5:00 pm6:00 pm7:00 pm8:00 pm9:00 pm10:00 pm11:00 pmEnd Time*AnyNone12:00 am1:00 am2:00 am3:00 am4:00 am5:00 am6:00 am7:00 am8:00 am9:00 am10:00 am11:00 am12:00 pm1:00 pm2:00 pm3:00 pm4:00 pm5:00 pm6:00 pm7:00 pm8:00 pm9:00 pm10:00 pm11:00 pmMonday* Monday Start Time*AnyNone12:00 am1:00 am2:00 am3:00 am4:00 am5:00 am6:00 am7:00 am8:00 am9:00 am10:00 am11:00 am12:00 pm1:00 pm2:00 pm3:00 pm4:00 pm5:00 pm6:00 pm7:00 pm8:00 pm9:00 pm10:00 pm11:00 pmEnd Time*AnyNone12:00 am1:00 am2:00 am3:00 am4:00 am5:00 am6:00 am7:00 am8:00 am9:00 am10:00 am11:00 am12:00 pm1:00 pm2:00 pm3:00 pm4:00 pm5:00 pm6:00 pm7:00 pm8:00 pm9:00 pm10:00 pm11:00 pmTuesday* Tuesday Start Time*AnyNone12:00 am1:00 am2:00 am3:00 am4:00 am5:00 am6:00 am7:00 am8:00 am9:00 am10:00 am11:00 am12:00 pm1:00 pm2:00 pm3:00 pm4:00 pm5:00 pm6:00 pm7:00 pm8:00 pm9:00 pm10:00 pm11:00 pmEnd Time*AnyNone12:00 am1:00 am2:00 am3:00 am4:00 am5:00 am6:00 am7:00 am8:00 am9:00 am10:00 am11:00 am12:00 pm1:00 pm2:00 pm3:00 pm4:00 pm5:00 pm6:00 pm7:00 pm8:00 pm9:00 pm10:00 pm11:00 pmWednesday* Wednesday Start Time*AnyNone12:00 am1:00 am2:00 am3:00 am4:00 am5:00 am6:00 am7:00 am8:00 am9:00 am10:00 am11:00 am12:00 pm1:00 pm2:00 pm3:00 pm4:00 pm5:00 pm6:00 pm7:00 pm8:00 pm9:00 pm10:00 pm11:00 pmEnd Time*AnyNone12:00 am1:00 am2:00 am3:00 am4:00 am5:00 am6:00 am7:00 am8:00 am9:00 am10:00 am11:00 am12:00 pm1:00 pm2:00 pm3:00 pm4:00 pm5:00 pm6:00 pm7:00 pm8:00 pm9:00 pm10:00 pm11:00 pmThursday* Thursday Start Time*AnyNone12:00 am1:00 am2:00 am3:00 am4:00 am5:00 am6:00 am7:00 am8:00 am9:00 am10:00 am11:00 am12:00 pm1:00 pm2:00 pm3:00 pm4:00 pm5:00 pm6:00 pm7:00 pm8:00 pm9:00 pm10:00 pm11:00 pmEnd Time*AnyNone12:00 am1:00 am2:00 am3:00 am4:00 am5:00 am6:00 am7:00 am8:00 am9:00 am10:00 am11:00 am12:00 pm1:00 pm2:00 pm3:00 pm4:00 pm5:00 pm6:00 pm7:00 pm8:00 pm9:00 pm10:00 pm11:00 pmFriday* Friday Start Time*AnyNone12:00 am1:00 am2:00 am3:00 am4:00 am5:00 am6:00 am7:00 am8:00 am9:00 am10:00 am11:00 am12:00 pm1:00 pm2:00 pm3:00 pm4:00 pm5:00 pm6:00 pm7:00 pm8:00 pm9:00 pm10:00 pm11:00 pmEnd Time*AnyNone12:00 am1:00 am2:00 am3:00 am4:00 am5:00 am6:00 am7:00 am8:00 am9:00 am10:00 am11:00 am12:00 pm1:00 pm2:00 pm3:00 pm4:00 pm5:00 pm6:00 pm7:00 pm8:00 pm9:00 pm10:00 pm11:00 pmSaturday* Saturday Start Time*AnyNone12:00 am1:00 am2:00 am3:00 am4:00 am5:00 am6:00 am7:00 am8:00 am9:00 am10:00 am11:00 am12:00 pm1:00 pm2:00 pm3:00 pm4:00 pm5:00 pm6:00 pm7:00 pm8:00 pm9:00 pm10:00 pm11:00 pmEnd Time*AnyNone12:00 am1:00 am2:00 am3:00 am4:00 am5:00 am6:00 am7:00 am8:00 am9:00 am10:00 am11:00 am12:00 pm1:00 pm2:00 pm3:00 pm4:00 pm5:00 pm6:00 pm7:00 pm8:00 pm9:00 pm10:00 pm11:00 pmHave 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 GEDDo you have a High School Diploma or GED?* High School Diploma GED High School*NameCity*CityState*StateYear Graduated*Year GraduatedTrade/Tech SchoolNameCityCityStateStateTradeTradeCertificate ReceivedCertificate ReceivedYear GraduatedYear GraduatedCollege/UniversityNameCityCityStateStateMajorMajorDegree ReceivedDegree ReceivedYear GraduatedYear GraduatedList 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 HISTORYPlease 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 UploadMax. file size: 100 MB.Company #1*NameAre you currently working for this employer?*Are you currently working for this employer? Yes No City*CityState*StatePhone Number*Phone NumberSupervisor's Name*Supervisor's NameMay 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 TitleSalary*SalaryDuties*DutiesReason for leaving*Reason for leavingCompany #2NameAre you currently working for this employer?Are you currently working for this employer? Yes No CityCityStateStatePhone NumberPhone NumberSupervisor's NameSupervisor's NameMay we contact?May we contact? Yes No Employment StartEmployment Start MM slash DD slash YYYY Employment EndEmployment End MM slash DD slash YYYY Job TitleJob TitleSalarySalaryDutiesDutiesReason for leavingReason for leavingCompany #3NameAre you currently working for this employer?Are you currently working for this employer? Yes No CityCityStateStatePhone NumberPhone NumberSupervisor's NameSupervisor's NameMay we contact?May we contact? Yes No Employment StartEmployment Start MM slash DD slash YYYY Employment EndEmployment End MM slash DD slash YYYY Job TitleJob TitleSalarySalaryDutiesDutiesReason for leavingReason for leavingList 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*RelationshipYears Known*Years KnownPhone*PhoneEmailEmail Reference Name #2* First Last Relationship*RelationshipYears Known*Years KnownPhone*PhoneEmailEmail Reference Name #3* First Last Relationship*RelationshipYears Known*Years KnownPhone*PhoneEmailEmail 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