Job Application: CASE MANAGER EMERGENCY DEPARTMENT

Fields marked with an asterisk (*) must be filled out before submitting.

Address
City *
State *
Post code *
Country
Telephone *
Cell phone
Best time to call
Email Address *
Type of employment desired	Full-Time Part Time Temporary On-Call
If under 18 can you furnish a work permit? *	Yes No
Have you filed an application here before? *	Yes No
Have you been employed here before? *	Yes No
Are you legally eligible for employment in this country? *	Yes No
Date available for work *
Shift Desired *	1st Shift 2nd Shift 3rd Shift
Will you work overtime if required? *	Yes No
Have you been convicted of a felony? *	Yes No
If yes, please explain

License Type
Organization or State Issued	Organization State
Original License/Certificate Date & Year Issued
Number
Are you currently registered?	Yes No
Are you eligible for registry?
Do you have a degree?	Yes No
Will take board examination

Please list office machines you are capable of using
Typing WPM
Dictation WPM
Computer Literate	Yes No
Please list equipment you can operate
Any additional comments

List your last three (3) employers, assignments, or volunteer activities, starting with the most recent including military experience. Explain any gaps in employment in comments section below.
Employer
Address
Telephone
Job Title
Immediate Supervisor and Title
Reason for Leaving
Date Employed from
Date Employed to
Still employed	Yes No

Employer
Telephone
Address
Job Title
Immediate Supervisor and Title
Reason for Leaving
Date Employed from
Date Employed to

Employer
Telephone
Address
Job Title
Immediate Supervisor and Title
Reason for Leaving
Date Employed from
Date Employed to

School Name
Years Completed
Degree Diploma
Major
Minor

Additional Information
Please list any additional information you would like to include
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