Job Application for Shine Pediatrics Step 1 - Applicant Information Name* Email* Street* City* State* Zip Code* Phone Number* Date Available to Begin* Social Security Number Which position are you applying for? * Medical Office ReceptionistMedical AssistantBilling TeamProvider Desired Pay (Please indicate salary or hourly rate) * Next Step: Employment Eligibility Step 2 - Employment Eligibility Are you legally eligible to work in the United States? * YesNoOther If no, are you authorized to work in the U.S. YesNo Have you ever worked for this company? * YesNoOther Have you ever been convicted of a felony?* YesNo If yes, explain Back to Applicant InformationNext Step: Education Step 3 - Education High School High School* Address Start Date Graduation Date Did you graduate?* YesNo College College* Address Start Date Graduation Date Did you graduate?* YesNoBack to Employment EligibilityNext Step: References Step 4 - References Reference 1 Full Name and Relationship* Company, address, and phone number* Reference 2 Full Name and Relationship* Company, address, and phone number* Reference 3 Full Name and Relationship* Company, address, and phone number*Back to EducationNext Step: Previous Employment Step 5 - Previous Employment Company 1 Company Name* Address* Phone* Supervisor* Job Title* Starting Salary Ending Salary Responsibilities* Start Date Graduation Date Reason for leaving* Company 2 Company Name* Address* Phone* Supervisor* Job Title* Starting Salary Ending Salary Responsibilities* Start Date Graduation Date Reason for leaving* May we contact your previous supervisor for a reference?* YesNoBack to ReferencesNext Step: Military Service (Optional) Military Service (Optional) Branch Start Date Graduation Date Rank at discharge DISCLAIMER AND SIGNATURE I CERTIFY THAT MY ANSWERS ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE. IF THIS APPLICATION LEADS TO MY EMPLOYMENT, I UNDERSTAND THAT FALSE OR MISLEADING INFORMATION IN MY APPLICATION OR INTERVIEW MAY RESULT IN MY RELEASE. Back to Previous Employment
