Arizona Medical Billing Service and Medical Practice Management based in Scottsdale

9827 N. 95th Street, Suite 105
Scottsdale, Arizona 85258
Telephone: 480.991.8100
Facsimilie: 480.603.2274

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Employment

To be considered for employment with Asterino and Associates, Inc., please fill out the form below.

1. Name (first/middle/last):
2. Address: Street:
City:
State:
Zipcode:
3. Telephone Numbers: Daytime:
Evening:
4. E-mail:
5. Are you at least 18 years of age?	Yes No
6. Position Applying For:
7. Minimum Acceptable Salary: $
8. Employment Desired:	Full-Time (regular) Full-Time (temp) Part-Time (regular) Part-Time (temp)
9. Convicted of a Felony: Have you, under this name or any other name, ever been convicted of a felony or a felony that was reduced to a misdemeanor for sentencing purposes including DWI? (Excluding any minor traffic violations only.) * Disclosure of previous convictions will not disqualify you from consideration.	Yes No
If yes, state of the offense, location, date, and disposition:
10. Do you have authorization to work in the U.S.?	Yes No
If yes, please select one of the following:	U.S. Citizen Resident Alien Work Permit or VISA
If Work Permit or VISA, which type:
11. Are you a veteran?	Yes No
If yes, check any that apply:	Vietnam Disabled
12. Referred By:	Newspaper Government Agency Friend/Relative Other
If other, please describe:
13. Computer Skills: (select specific area(s) in which you are experienced.)	Word Processing Applications (i.e. Word, WordPerfect) Spreadsheet Applications (i.e. Excel, Lotus) Presentation Applications (i.e. Power Point) Database Applications (i.e. Access, ACT, D-Base, ABRA) Other Typing
If other, please describe:
If typing, estimated words per minute:
14. Education: Do you have a high school diploma or GED?	Yes No
Total Years Completed:
Name of High School:
Completed:	Yes No
Name of College:
Completed:	Yes No
Degree:
Name of College:
Completed:	Yes No
Degree:
Name of Technical School:
Completed:	Yes No
Degree:
Name of Technical School:
Completed:	Yes No
Degree:
15. Work Experience: (list most recent employer first)
Company Name:
Address:
Job Title:
Salary(per hour): $
Duties/Responsibilities:
Employed from (date):
Employed to (date):
Reason for Leaving:
May we contact this employer?	Yes No
If no, explain:
Company Name:
Address:
Job Title:
Salary(per hour): $
Duties/Responsibilities:
Employed from (date):
Employed to (date):
Reason for Leaving:
May we contact this employer?	Yes No
If no, explain:
Company Name:
Address:
Job Title:
Salary(per hour): $
Duties/Responsibilities:
Employed from (date):
Employed to (date):
Reason for Leaving:
May we contact this employer?	Yes No
If no, explain:
Company Name:
Address:
Job Title:
Salary(per hour): $
Duties/Responsibilities:
Employed from (date):
Employed to (date):
Reason for Leaving:
May we contact this employer?	Yes No
If no, explain:
Company Name:
Address:
Job Title:
Salary(per hour): $
Duties/Responsibilities:
Employed from (date):
Employed to (date):
Reason for Leaving:
May we contact this employer?	Yes No
If no, explain:
If you have a resume, please upload it now.
All statements and responses made on the application and/or resume for employment may be verified by a background investigation which may include employment history, criminal record, education and license(s)/certificate(s) as appropriate. If any statement I make either on the application form or during the employment process, is found to be false or misleading, consideration of the application may be discontinued. I understand that if employed, I am subject to dismissal if any of the information on this application is false, or has been omitted and that I may be required to furnish documents supporting statements herein.
Applicant Signature (type name):
Date:
Asterino and Associates, Inc. is committed to a policy of equal opportunity for all ages, regardless of race, color, religion, national origin, sex, handicap or veteran status. Thank you for applying with our Group.

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