ScribeMD - Application Form

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On-Line Employment Application

Application

Company Policy, federal and state law prohibit discrimination on the basis of race, color, religion, national origin, sex,
age or handicap.

Personal:

Last:

Name

First:

Tiffany

Arendon

Address

Street:

City:

Social Security#:

Email Address:

Telephone Number

Home:

Cell:

Address:

City:

Middle Initial:

D
State:

Zip:

State:

Zip:

Emergency Contact Info

Name:
Telephone Number:

Previous Employment:

I. Company Name:

Address:

Telephone:

Job Title:

Supervisors Name:

Supervisors Title:

Type of Business:

Description of Duties:

Date Employed (##/##)

From:

To:

Base Rate of Pay (Hr/Week/Month)

Start Date End Date (##/##/##)
Start:

End:

Reason for Leaving:

II. Company Name:

Address:

Telephone:

Job Title:

Supervisors Name:

Supervisors Title:

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Type of Business:

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Description of Duties:

Date Employed (##/##)

From:

To:

Base Rate of Pay (Hr/Week/Month)

Start Date End Date (##/##/##)
Start:

End:

Reason for Leaving:

III. Company Name:

Address:

Telephone:

Job Title:

Supervisors Name:

Supervisors Title:

Type of Business:

Description of Duties:

Date Employed (##/##)

From:

To:

Base Rate of Pay (Hr/Week/Month)

Start Date End Date (##/##/##)
Start:

End:

Reason for Leaving:

Education:

High School Name:

Year Completed:
GPA:
College University Name:
Year Completed:
Diploma/Degree:
GPA:
Major:
College University Name:
Year Completed:
Diploma/Degree:
GPA:
Major:
Graduate:

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Years Completed:
Study of Focus:
GPA:

References:
List people we may contact who are qualified to evaluate your capabilities (Do not include relatives)
Name:

Address:

City:

Occupation:

Years Known:

Telephone:

Name:

Address:

City:

Occupation:

Years Known:

Telephone:

Name:

Address:

City:

Occupation:

Years Known:

Telephone:

State:

Zip:

State:

Zip:

State:

Zip:

Scheduling:
1. When are you available to start?

2. Do you want Track 1 or Track 2?(please specify why)

3. If Track 1,specify your availability. (day of week and time of day/night)

4. Can you commit to 2 years of work?

5. If Track 2, specify your availability. (day of week and time of day/night)

6. Can you work weekends, holidays, night shifts?

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7. Do you have a means of transportation to and from the hospital?

8. How were you referred to our company?

9. Have you ever applied at this company before?

10. Have you ever been employed as a scribe at this company or another hospital?

11. Are you currently employed?

12. If yes, may we contact your current job? (Enter Telephone Number)

Questions:
1. Do plan to have a career in the medical field? (please explain)

2. What is your primary language?

3. Do you speak any other languages?

4. Could you translate any other languages?

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5. Are you experienced in the Medical field?

6. Do you have a basic understanding of medical terminology?

7. Are you EMT certified?

8. Have you worked in the Medical field?

9. Which biology courses have you taken?

10. How did you hear about the scribe position?

11. Why do you want to be a scribe?

12. Any activities that you partake in on your free time?

13. What are your hobbies?

14. What are your most valued qualities?

15. What is your favorite quote and why?

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16. How do you deal with stressful situations? (give example)

17. Please list any honors or awards received:

18. US Military Service (YES/NO)

19. Which Branch of the Military?

20. Highest Rank Earned?

21. US Military Duties that relate to this job

22. List any Special Training

Please read the following statements carefully before signing this application. Only those applications
that are signed and dated are considered valid. I certify that all answers or statements I have made on
this application or on my resume or other supplementary materials are true and correct without
omissions. I acknowledge that any false statement or misrepresentation on this application or
supplementary materials will be cause for refusal to hire or for immediate dismissal from employment at
any time during the period of my employment. I authorize my past employers and/or schools to furnish
any information concerning my previous employment and/or education. I release this company and all
persons and organizations from all claims and liabilities of any nature arising from such investigations or
the supplying of information for such investigations. In making this application for employment I also
understand that an investigative consumer report may be made whereby information is obtained through
personal interviews with my neighbors, friends or others with whom I am acquainted. This inquiry
may include information on my character, general reputation, and personal characteristics. I understand
that I have the right to make a written request within a reasonable period of time to receive additional,
detailed information about the nature and scope of this investigative consumer report. I have no
objection to making application for a fidelity bond or security clearance, signing an employee agreement
on confidential information and inventions or taking a physical/medical examination at any time at the
option and expense of the company. If hired, I will be required to submit proof of U.S. citizenship.
I understand that my employment is for no definite period of time and may be terminated at any time by
the company or by me with or without cause. I have read and understand the foregoing statements and
accept the same as conditions of employment.

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ScribeMD - Application Form

Signature
Date:
Submit

of

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Applicant

Reset

Emergency Medicine
Specialists of Orange County
1010 W. La Veta Ave. Ste 755
Orange, CA 92868
714.543.8911

5/22/2007