Application for Employment

Please read carefully and fill out all the fields. The questions on this application enable us to properly evaluate your ability and chance for success in the position for which you are applying. Your applications will not be processed unless all questions are answered.

This application conforms to Federal and State laws. Prima CARE, P.C. is an equal opportunity employer and does not discriminate because of color, race, sex, religion, age, national origin, disability or sexual orientation. Prima CARE, P.C. will reasonably accommodate qualified disabled applicants in the workplace.

It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability. Prima CARE, P.C. will conduct a background check upon an interview.

Prima CARE, P.C. will conduct a background check upon an interview.

Current Job Openings:

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PERSONAL INFORMATION

Patient First Name

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Middle Name

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Patient Last Name

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Address (Street, City, State & Zip)

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Home Phone

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Cell Phone

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Email Address

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Are you 18 years or older?

Yes

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Are you a citizen of the U.S.?

Yes

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If not, do you have a legal right to remain and work in the U.S.?

Yes

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If yes, list visa number

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Have you been convicted of a felony within the last five years?

Yes

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If yes, please explain and list dates

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Do you have any relatives employed by Prima CARE?

Yes

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If yes, list names, division and job function

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Start with your present or last job. Give a complete history of employment experience and reasons for period unemployment during the past ten years. Begin with the most recent employment. You may include in this work history any verifiable work performed on a volunteer basis. Please complete this section in detail.

Present or last job:

Employer

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Job title

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Address (Street, City, State & Zip)

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May we contact this employer?

Yes

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Main Phone Number:

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Supervisor

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Supervisor's Phone Number

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Employed - Date Started & Date Ending

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Starting Rate

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Final Rate:

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Reason for leaving:

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Description of duties:

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Other Job

Employer

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Job title

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Address (Street, City, State & Zip)

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May we contact this employer?

Yes

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Main Phone Number

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Supervisor

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Supervisor's Phone Number

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Employed - Date Started & Date Ending

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Starting Rate

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Final Rate

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Reason for leaving

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Description of duties:

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Other Job

Employer

Please complete this field.

Job title

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Address (Street, City, State & Zip)

Please complete this field.

May we contact this employer?

Yes

Please select an option.

Main Phone Number

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Supervisor

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Supervisor's Phone Number

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Employed - Date Started & Date Ending

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Starting Rate

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Final Rate

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Reason for leaving

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Description of duties

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EDUCATION

Elementary

Elementary School Address

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Years Attended:

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High School

High School Name

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High School Address

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Years Attended

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Degree/Diploma

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College

College Name

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College Years Attended

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College Degree/Diploma

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Course of study

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Trade, Business or Correspondence School

Name of trade, business or correspondence school

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Address:

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Years Attended

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Degree/Diploma

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Course of study

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Office Skills

Check All that apply:

Typing

Typing words per minuet

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Shorthand

Shorthand words per minuet

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Dictaphone

Medical Terminology

Third-Party Billing

Filing

Receptionist

Data Entry

Bookkeeping

Accounting

Word Processing

Software Packages you are proficient in:

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Other Relevant Skills:

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REFERENCES

Complete names, addresses and phone numbers of three references who are not relatives or previous employers. This is needed to verify your qualifications for the position. If this section is not completed in full, a delay in processing your application for employment will result.

First Reference

Reference Name

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Company

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Reference Phone number

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Second Reference

Second Reference Name

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Company

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Phone Number:

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Third Reference

Third Reference Name

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Company

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Phone Number

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Resume

I certify that the answers given by me to the foregoing questions and statements are true and correct without consequential omissions of any kind whatsoever. I agree the Prima CARE, P.C. shall not be liable in any respect if my employment is terminated because of falsity of statements, answers or omissions made by me in this questionnaire. I authorize the medical facilities companies, schools or persons named to give nay information regarding me. I herby release said medical facilities, companies, schools, and persons from all liability for any damage for issuing this information. In addition, if accepted for employment, I herby agree to abide by the rules and policies of my employer and accept the established pay period as provided in accordance with the Fair Labor Standards Act (as amended).

I understand that, upon an offer of employment, I need to conform with The Immigration Reform and Control Act of 1986. I further understand that failure to do so will prohibit me from starting employment.

I understand that employment is contingent upon successful completion of a physical examination given by a provider of the employee's choice.

I understand that if I am hired, my hiring will not be considered as creating a contractual relationship for a definitive term between me and Prima CARE, P.C. I thus understand that, unless otherwise specifically set forth in a separate written document signed by me and by an authorized representative of Prima CARE, P.C., I will be employed ‘at will’ meaning that either I or Prima CARE, P.C. may terminate my employment at any time.

Do you agree to the terms described above?

Yes, I have read and agree to the terms listed above.

Please send your resume to ssmith@prima-care.com

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