Application For Employment

Personal Data

Name:    

Address:  

City:                     State:              Zip Code:   

Daytime Phone:             Evening Phone:   

Social Security Number:        Are You A US Citizen?    Yes No    

If under 18, state your age: 

Email Address: 

General Information

Position Applying For:   

How did you learn of this opening?   

If hired, on what date would you be able to start?   

Do you have any physical, mental or medical impairment or disability that would limit your job performance in the position that your are applying for?    Yes No

 If yes, please explain:                                                                 

Education

Type of School                          

Name of School/Location        Dates Attended               Graduate?          Degree

High School College or University Graduate School Vocational or Trade School Other

         Yes No       

High School College or University Graduate School Vocational or Trade School Other

         Yes No       

High School College or University Graduate School Vocational or Trade School Other

         Yes No       

High School College or University Graduate School Vocational or Trade School Other

          Yes No       

Business/Professional References (May be contacted by AMT)

Name                                  Organization/Location                         Title                                 Phone

Other Information

State any additional skills, qualifications, or experience you feel may be helpful, including computer knowledge:

Typing Speed:   

Software Used:

Internet Ready? (Y/N)  Yes No           Fax? (Y/N)  Yes No

Do you have high speed Internet access? (DSL,Cable,Satellite)  Yes No

Employment/Military Experience

Present or Last Employer

Employer:      City,State: 

Telephone:      Dates Employed from    to 

Salary:      May we contact?  Yes No     Job Title: 

Supervisor's Name:      Job Title: 

Your Duties:  

Reason for Leaving: 

Next Previous Employer

Employer:      City,State: 

Telephone:      Dates Employed from    to 

Salary:      May we contact?  Yes No     Job Title: 

Supervisor's Name:      Job Title: 

Your Duties:  

Reason for Leaving: 

Next Previous Employer

Employer:      City,State: 

Telephone:      Dates Employed from    to 

Salary:      May we contact?  Yes No     Job Title: 

Supervisor's Name:      Job Title: 

Your Duties:  

Reason for Leaving: 

What makes you think that you are ready for this challenge?

Employment Agreement

Employment Application Accuracy

I certify that the answers and statements given above are true and complete.  I understand that any false statements on the application may cause the withdrawal of any job offer or, if employed, the termination of my employment.

I also understand that if I choose to work from my home, I will be considered a sub-contractor, not an employee of AMT, and will be responsible for my own payroll taxes.

Secrecy Agreement

I understand that medication information is a confidential communication.  I also understand that as a transcriptionist or a courier, I should never mention the name of a patient or others outside the company.  Nor should I discuss a patient's condition with the patient or patient's family or within hearing distance of people outside the company.  This includes my own family.  Everything I see, hear or read about a patient is strictly confidential.  Records, appointment books, charts and ledgers should not be left where unauthorized people will have access to them.  I further understand that a violation of this policy will automatically terminate my position with the company.

Pre-Employment Hearing Exam

I understand that, if I receive a job offer, I may be required to take a hearing test.  This test will be conducted by a licensed physician designated by AMT.

Prospective employees who refuse to take the test will not be hired.

Prospective employees who fail the test will be informed of the results and will not be considered for employment.  The prospective employee who has failed may request in writing a second test.  This test will be at the expense of the prospective employee.

I understand AMT's pre-employment hearing exam and I agree, if asked, to complete the test as part of the employment process.

Authorization

By submitting this application, I indicate that I have read and understand the Employment Agreement and agree to abide by these policies if I am employed by AMT.