Online Application

Med-Scribe Secure Employment Application Form

IMPORTANT: Individual jobs need to be listed for each position held for the last 5 years. Do not cut and paste your resume. Applications must show a complete employment history for the past five years. Please follow instructions in blue bars above each section.

PLEASE READ BEFORE BEGINNING THIS APPLICATION: Only one application is needed every six months. Please ONLY send us the numbers of the positions for which you would like to be considered. To be considered for additional positions after the application is submitted, please call 585-586-0790 and have the job number available, or email the job number to medjobs@medscribe.com with your name in the subject line. Thank you.

Med-Scribe, Inc. is an Equal Opportunity Employer / Minority / Female / Disability / Vet.

Mandatory fields marked with *

General Information

Name*

(Last)

(First)

Have you ever worked under another name?* Yes No

If Yes, please list

Street Address*

City*

State*

Zip*

Phone Number*

Position(s) applied for*

Please apply to a MAXIMUM OF 5 jobs (Please hold ctrl or command to select more than one position.)

Email Address (If Available):

Are you able to Temp? Yes No

Hours per week sought*

Are you currently employed?* Yes No

Are you legally authorized to work in the US?* Yes No

ALL LICENSED PROFESSIONALS MUST COMPLETE OR YOUR APPLICATION WILL NOT BE CONSIDERED

Professional Registration Number Expires

If you’re a Licensed Medical Professional (i.e.: Nurse/NP/PA etc), has your license to practice in any jurisdiction ever been denied, terminated, limited, revoked, suspended, or voluntarily / involuntarily subject to probationary terms, or is there a pending action or challenge to do so? No Yes

If yes, explain:

Have you ever been asked to resign or face termination? No Yes

If yes, explain:

Are you over the age of 18?* Yes No

Please indicate Days & Hours available*

Salary desired*

Date available*

Geographic location in which you will accept assignments*

NYC residents: YOU ARE NOT REQUIRED TO RESPOND TO CONVICTION QUESTION.

Have you ever been convicted of a crime? Yes No

If Yes, please list (include date of convictions) and explain:

Criminal convictions are not necessarily a bar to employment; we evaluate the job-relatedness of the conviction

the nature and gravity of the criminal offense or conduct
the nature of the job (including where it is performed, how much supervision and interaction with others the employee will have, and so on), and
how much time has passed since the offense or sentence.

Have you interviewed with Med-Scribe, Inc. in the past?* Yes No

How did you learn about Med-Scribe?* Select One: …if Other

Education

High School, Address, Diploma Received* College/Business School, Address, Diploma Received

Personal References (no relatives) who have known you for at least one year:

Name, Address, Phone, Occupation*

Work Experience (Incompleteness will not be interpreted in your favor):

Do you object to Med-Scribe making inquiries regarding your past qualifications and job performance?* Yes No

If Yes, where?

1. Dates of Employment (Start with most recent position first)
IMPORTANT – individual jobs need to be listed and questions answered for each position held for the last 5 years

If this is your 1st job and you have no previous employment history, please enter NA (Not Applicable) in all the fields below.

Start Date:*

End Date:*

Name and address of employer*

Phone*

Hours per week*

Position*

Name and Title of supervisor*

Reason for leaving*

Description of job responsibilities*

Click to Add Work Experience #2

2. Dates of Employment
IMPORTANT – individual jobs need to be listed and questions answered for each position held for the last 5 years

Start Date:

End Date:

Name and address of employer

Phone

Hours per week

Position

Name and Title of supervisor

Reason for leaving

Description of job responsibilities

Click to Add Work Experience #3

3. Dates of Employment
IMPORTANT – individual jobs need to be listed and questions answered for each position held for the last 5 years

Start Date:

End Date:

Name and address of employer

Phone

Hours per week

Position

Name and Title of supervisor

Reason for leaving

Description of job responsibilities

Click to Add Work Experience #4

4. Dates of Employment
IMPORTANT – individual jobs need to be listed and questions answered for each position held for the last 5 years

Start Date:

End Date:

Name and address of employer

Phone

Hours per week

Position

Name and Title of supervisor

Reason for leaving

Description of job responsibilities

Click to Add Work Experience #5

5. Dates of Employment
IMPORTANT – individual jobs need to be listed and questions answered for each position held for the last 5 years

Start Date:

End Date:

Name and address of employer

Phone

Hours per week

Position

Name and Title of supervisor

Reason for leaving

Description of job responsibilities

Click to Add Work Experience #6

6. Dates of Employment
IMPORTANT – individual jobs need to be listed and questions answered for each position held for the last 5 years

Start Date:

End Date:

Name and address of employer

Phone

Hours per week

Position

Name and Title of supervisor

Reason for leaving

Description of job responsibilities

Click to Add Work Experience #7

7. Dates of Employment
IMPORTANT – individual jobs need to be listed and questions answered for each position held for the last 5 years

Start Date:

End Date:

Name and address of employer

Phone

Hours per week

Position

Name and Title of supervisor

Reason for leaving

Description of job responsibilities

Click to Add Work Experience #8

8. Dates of Employment
IMPORTANT – individual jobs need to be listed and questions answered for each position held for the last 5 years

Start Date:

End Date:

Name and address of employer

Phone

Hours per week

Position

Name and Title of supervisor

Reason for leaving

Description of job responsibilities

Click to Add Work Experience #9

9. Dates of Employment
IMPORTANT – individual jobs need to be listed and questions answered for each position held for the last 5 years

Start Date:

End Date:

Name and address of employer

Phone

Hours per week

Position

Name and Title of supervisor

Reason for leaving

Description of job responsibilities

Click to Add Work Experience #10

10. Dates of Employment
IMPORTANT – individual jobs need to be listed and questions answered for each position held for the last 5 years

Start Date:

End Date:

Name and address of employer

Phone

Hours per week

Position

Name and Title of supervisor

Reason for leaving

Description of job responsibilities

If you have additional working experience please list below:
(Do not copy and paste your resume

Additional working experience

I declare that the statements made in this application (including statements made in accompanying papers) have been examined by me and that they are true and correct. I understand that falsification of this application is grounds for immediate termination.

I agree* (Signature will be added at interview)

Upon successfully submitting your application, you will be redirected to our Voluntary Information form. Thank you!

Med-Scribe, Inc. is an Equal Opportunity Employer
NYS Certified Woman Owned Business
Safety Trained

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