Certified Medical Assistant | The Memphis Medical Society

Full Name *

Last, First, Middle Initial

Email *

Date

Preferred Name

Home Address

City

State/Province

Zip/Postal

Country

Cell Phone

Other Phone

Upload your resume here and continue filling out the online form.

Drop a file here or click to upload Choose File

Maximum upload size: 67.11MB

Are you under 18 years old?

Yes

No

If you are under 18, and it is required, can you furnish a work permit? Please explain.

Have you ever been employed here before?

Yes

No

If yes, please give dates and positions.

Are you legally eligible for employment in this country?

Yes

No

Date Available to Begin Work

What is your desired salary?

Type of employment desired

Are you bilingual?

Yes

No

Are you able to meet the attendance requirement of the position?

Yes

No

Do you smoke?

Yes

No

Have you ever pled guilty or no contest to, or have been convicted of a crime?

Yes

No

Answering YES to this question does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will all be taken into account.

Driver's license number and state

Skills and Qualifications

Summarize any training, skills, licenses and/or certifications that may qualify you for this job.

Educational Background

Education Background

Name and location of high school

Number of years completed

Did you graduate?

Yes

No

Course of study

Name and location of college

Number of years completed

Did you graduate?

Yes

No

Course of study

Other education

Employment History

Please complete your employment history

From

To

Employer

Phone

Employer Address

City

State/Province

Zip/Postal

Starting/Ending Job Titles

Supervisor and Title

Summarize the nature of work and job responsibilities you did

May we contact for reference?

Yes

No

Starting/Ending Salaries

Reason for leaving

Employment History continued

From

To

Employer

Phone

Employer Address

City

State/Province

Zip/Postal

Country

Starting/Ending Job Titles

Supervisor and Title

Summarize the nature of work and job responsibilities you did

May we contact for reference?

Yes

No

Starting/Ending Salaries

Reason for leaving

Employment History

Please complete your employment history below

From

To

Employer

Phone

Employer Address

City

State/Province

Zip/Postal

Country

Starting/Ending Job Titles

Supervisor and Title

Summarize the nature of work and job responsibilities you did

May we contact for reference?

Yes

No

Starting/Ending Salaries

Reason for leaving

References

Please list your references below

Full Name

Phone

Email

Number of years known

Full Name

Phone

Email

Number of years known

Full Name

Phone

Email

Number of years known

Applicant Statement

I certify that all information I have provided in order to apply for and secure work with the employer is true, complete and correct.

I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect will be sufficient cause to 1. cancel further consideration of this application and/or 2 immediately discharge me from the employer's service whenever discovered.

I expressly authorize, without reservation, the employer, its representative, employees or agents to contract and obtain information from all references, employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives for seeking, gathering and using such information in the employment process and all other persons, corporations or organizations for furnishing such information about me. 
I understand that the employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limited or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state or federal law. 
I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to reapply and fill out a new application. 
If I am hired, I understand that I am free to resign at any time, with or without cause, and without prior notice, and the employer reserves the same right to terminate my employment at any time with our without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied, oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer's president. 
I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United State of American, and that federal immigration law require me to complete an I-9 form in this regard.

Signature

Online signature: *

Signature of application

Checking this box will stand as your online signature

Signed on: *

reCAPTCHA

Jobs

Certified Medical Assistant (CMA) | MedTemps

Uploading Files. Please Wait.

Educational Background

Employment History

Employment History continued

Employment History

References