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Medical Management Associates, Inc. - Healthcare Consulting Logo

3330 Cumberland Boulevard • Suite 200 • Atlanta, GA 30339
Phone: 770-951-8427 • Fax: 770-951-2157

Medical Management Associates, Inc. - Healthcare Consulting Logo

Job Application Form

Application for Employment: Pre-Employment Questionnaire, and an Equal Opportunity Employer

Personal Information
Date:
Last Name:
First Name:
Middle Initial:
E-Mail Address:
Social Security Number:
Present Address:
Apartment Number:
City:
State:
ZIP:
Permanent Address:
Apartment Number:
City:
State:
Zip Code:
Are you 18 years or older? Yes
No
Home Phone:
Cell Phone:
Are you either a U.S. citizen or an alien authorized to work in the United States? Yes
No
Background Information
Convicted of a felony or misdemeanor? ** Yes
No
Placed on probation or terminated for poor job performance? Yes
No
Disciplined or discharged for violating a safety rule? Yes
No
Disciplined or terminated for absenteeism, tardiness, failure to notify your company when absent or any other attendance-related reason? Yes
No
Disciplined or fired for fighting, assault or similar offenses? Yes
No
Disciplined or discharged for being under the influence of alcohol or drugs, or for possession, use or abuse of alcohol or drugs? Yes
No
If you answered yes to any of the above questions, please describe:
I understand that I may be required to provide information for employment, references, credit and background checks.

** You will not be denied employment solely because of a conviction record, unless the offense is related to the job for which you have applied.

Employment Desired
Position:
Date you can start:
Salary Desired:
Are you employed now? Yes
No
If so, may we inquire of your present employer? Yes
No
Ever applied to this company before? Yes
No
Where?
When?
Education
High School  
Name and Location of School:
Number of Years Attended:
Did you Graduate? Yes
No
Subjects Studied:

College  
Name and Location of School:
Number of Years Attended:
Did you Graduate? Yes
No
Subjects Studied:

Trade, Business or Correspondence School  
Name and Location of School:
Number of Years Attended:
Did you Graduate? Yes
No
Subjects Studied:
General
Subjects of Special Study or Research Work:
Present Membership in National Guard or Reserves:
Former Employers

List below your last three employers, starting with the most recent one first.

From (month/year):
To (month/year):
Name and Address of Employer:
Position:
Salary:
Reason for Leaving:

From (month/year):
To (month/year):
Name and Address of Employer:
Position:
Salary:
Reason for Leaving:

From (month/year):
To (month/year):
Name and Address of Employer:
Position:
Salary:
Reason for Leaving:
References

Below, give the names of three work-related references. Only give references you are prepared for MMA to contact.

References for current employer can be provided at a later date. Please only provide direct telephone numbers or extensions.

Name:
Address:
Phone Number:
Name of Business:
Years Known:

Name:
Address:
Phone Number:
Name of Business:
Years Known:

Name:
Address:
Phone Number:
Name of Business:
Years Known:
Physical Record

Do you have any physical limitations that preclude you from performing any work for which you are being considered?

Yes
No

If yes, what can be done to accommodate your limitation?
Please describe:

In Case of Emergency:

Name:  
Address:  
Phone Number:  

"I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.

I authorize investigation of all statements contained herein and the references listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you.

I understand and agree that, if hired, my employment is provided on an at-will basis for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without prior notice."

Date:
Signature:

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