Name*
First Middle Last
Home Phone
Cell Phone
Address
Street Address Address Line 2 City State ZIP Code
Email*

Position applied for
Salary desired
Have you ever applied here before?
When?
Date available for work
MM slash DD slash YYYY
Desired Hours

High School
Name / Address of School
Graduation Date

Undergraduate College
Name / Address of School
Course Study
Total Years of Study
Degree/ Diploma

Graduate/ Professional
Name / Address of School
Course Study
Total Years of Study
Degree/ Diploma

Other Education
Name / Address of School
Course Study
Total Years of Study
Degree/ Diploma
List any seminars, classes or other education not listed in other sections which may help qualify you for this position.
Seminars, Classes, and Other Education

May we contact your current employer?
Employer 1
Employer Name
Current Employer?
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Address
Street Address Address Line 2 City State ZIP Code
Phone
Fax
Supervisor(s) Name
Supervisor Email
Job Positions
Essential job functions of final position
Reason(s) for Leaving

Employer 2
Employer Name
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Address
Street Address Address Line 2 City State ZIP Code
Phone
Fax
Supervisor(s) Name
Supervisor Email
Job Positions
Essential job functions of final position
Reason(s) for Leaving

Employer 3
Employer Name
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Address
Street Address Address Line 2 City State ZIP Code
Phone
Fax
Supervisor(s) Name
Supervisor Email
Job Positions
Essential job functions of final position
Reason(s) for Leaving

Have you ever been employed with this company before?
If Yes, When?
Do you have any friends or rel atives employed by this company?
If Yes, please provide their names and relationship to you:
Are you currently employed?
May we contact your employers?
Are you 18 years or older?
If hired, can you pr ovide proof of U.S. citizenship or proof of your legal right to work in the U.S.?
Are you able to perform all of the essential functions of the job for which you are applying with or without reasonable accommodation?
If hired, are there any accommodations the company would need to provide so that you can perform all those essential functions and duties of the position being applied for?
If Yes, please explain:
If hired, do you have a reliable means of transportation to and from work?
If hired, are you available to work any shift/or any day of the week?
Have you ever been charged or convicted of a felony or misdemeanor?
If Yes, please explain:
A criminal record does not constitute an automatic bar to employment and will be considered only as it substantially relates to the job in question.

List three persons not related to you who have nowledge of your work performance within the last 5 years.
Reference 1
Name
First Last
Occupation
Company Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email
Relationship
Years Acquainted

Reference 2
Name
First Last
Occupation
Company Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email
Relationship
Years Acquainted

Reference 3
Name
First Last
Occupation
Company Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email
Relationship
Years Acquainted

Equal Employment Opportunity Statement
This company is committed to the principles of equal employment opportunity and is committed to make employment decisions based on merit. We are committed to complying with all Federal, State and local laws
providing for equal employment opportunities, as well as all laws related to terms and conditions of employment. The Company desires to maintain a work environment that is free of sexual harassment and
discrimination due to race, religion, color, sex, national origin, physical or mental disability, age with respect to persons 18 years or older, or any other status protected by Federal, State or local laws.
The Company will make reasonable efforts to accommodate those physical or mental limitations of an otherwise qualified employee unless undue hardship would result for the company.
Discrimination and Sexual Harassment Policy Statement
This Company will not tolerate any form of unlawful discrimination, including sexual harassment. Any employee who engages in unlawful discrimination or sexual harassment will be subject to
appropriate discipline, up to and including termination. Prohibited sexual harassment is defined as follows: Unwelcome sexual advances, requests for sexual favors and other verbal or physical conduct of a sexual nature constitutes sexual harassment when (1) submission to such conduct is made whether explicitly or implicitly a term or condition of an individual’s employment; (2) Submission to or action of such conduct by an individual is used as the basis for employment decisions affecting such individuals; or (3) Such conduct has the purpose or effect of unreasonably interfering with an individual’s work performance or creating an intimidating, hostile or offensive work environment.
Disclosure to Applicants Concerning Drug/Alcohol Testing
If you are offered a position with the Company, you may be given a drug/alcohol test as a condition of employment. Your refusal to timely submit to a drug/alcohol test or your failure to pass such a test means you will not be employed by this company. Neither the collector of specimens nor the medical professional who reviews the test results will be a company employee. The test results will be kept confidential. The individual undergoing testing will not be directly observed while providing the specimen unless there are reasonable grounds to believe the individual may alter or substitute the specimen. Negative test results are required as a condition of employment.
Complete and Accurate Information
I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I have personally completed this application. I understand that any omissionor misstatement of material fact on this application, or any other document used to secure employment, shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.
At-Will Employment
I understand and agree that if I am employed, my employment will be “at-will”, which means that the Company may terminate the employment relationship at any time, with or without cause and with or without notice. Likewise, the Company will respect my right to terminate my employment at any time, with or without cause and with or without notice. I further understand that any prior representation, whether expressed or implied to the contrary is hereby superceded and that no promise or representation contrary to the foregoing is binding on the Company unless made in writing and signed by the Company’s president.
Testing Authorization
If offered a position with the Company, I hereby agree to any legally permitted physical, psychological, skill, drug or medical test required by the Company as a condition of employment.
Investigation Authorization
I authorize investigation into all statements and references contained in this application. Said investigation may include credit, driving, criminal background, references and other background checks. By applying for this job, I also authorize post-hire investigation into my credit, driving and criminal background.
Company Obligation
I understand and agree that the Company’s acceptance of this job application does not mean that a position for which I am qualified is open (unless specifically posted) or that the company has agreed to hire me. I understand that the Company is under no obligation to hire me as the result of accepting this completed application
TOS Agreement*
- I Have Read and Agree to the Above
Full Name*
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Revenue Cycle Experts

Temp Employee Application

Step 1 of 14 – Personal Information

High School

Undergraduate College

Graduate/ Professional

Other Education

Affiliations Audits & Achievements

Revco Solutions Locations

Durham, NC (Corporate Headquarters)

Oradell, NJ

Jacksonville, FL

Dewitt, MI

Dayton, OH

Columbus, OH

Omaha, NE

Omaha, NE