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RCP Employment Application Form
Application For Employment
Applicants May Be Tested For Illegal Drugs

Applicant Information

PLEASE COMPLETE PAGES 1-5. DATE
Last Name First Name Middle Maiden
Present address
City State Zip
How long at this Address?
Social Security No
Telephone
Email Address


Employment Information

Position applied for
Hourly pay desired
How many hours can you work weekly?
Can you work evenings?
Days/hours available to work
No Pref Thur
Mon Fri
Tue Sat
Wed Sun
Employment desired FULL-TIME ONLY PART-TIME ONLY FULL- OR PART-TIME
When are you available for work?


Education

TYPE OF SCHOOL NAME OF SCHOOL LOCATION
(Complete mailing address)		 NUMBER OF YEARS
COMPLETED		 MAJOR & DEGREE
High School
College
Business Or Trade School
Professional School
HAVE YOU EVER BEEN CONVICTED OF A CRIME OTHER THAN A TRAFFIC VIOLATION? No Yes
If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation.


Driving History

DO YOU HAVE A DRIVER’S LICENSE? Yes No
What is your means of transportation to work?
Driver’s license number State of issue
Type Operator Commercial (CDL) Chauffeur
Expiration date
Have you had any accidents during the past three years?
Yes No 		How many?
Have you had any moving violations during the past three years?
Yes No 		How Many?


Computer Applications

Familiar with the following:
PC/Windows Applications
MS Excel MS Access MS PowerPoint MS Word
Email Internet    
Other PC Applications
Clinical and Hospital Applications
Meditech McKesson Siemens Cerner
Other Clinical and Hospital Applications
Call center management systems
3rd Party billing systems
Physician billing systems


References

Please list two references other than relatives or previous employers.
Name Name
Position Position
Company Company
Address Address
Address 2 Address 2
Telephone Telephone


An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the space below to summarize any additional information necessary to describe your full qualifications for the specific position for which you are applying.


Military

HAVE YOU EVER BEEN IN THE ARMED FORCES? Yes No
ARE YOU NOW A MEMBER OF THE NATIONAL GUARD? Yes No
Specialty Date Entered Discharge Date


Previous Work Experience

Please list your work experience for the past five years beginning with your most recent job held.
If you were self-employed, give firm name. Attach additional sheets if necessary.
Name of employer
Address
City
State
Zip Code
Phone number
Your last job title
Name of last supervisor Employment dates (Mo/Yr) Pay or salary
  From Start
  To Final
 
Reason for leaving (be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

Position 2
Name of employer
Address
City
State
Zip Code
Phone number
Your last job title
Name of last supervisor Employment dates (Mo/Yr) Pay or salary
  From Start
  To Final
 
Reason for leaving (be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

Position 3
Name of employer
Address
City
State
Zip Code
Phone number
Your last job title
Name of last supervisor Employment dates (Mo/Yr) Pay or salary
  From Start
  To Final
 
Reason for leaving (be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.
May we contact your present employer? Yes No
Did you complete this application yourself? Yes No
If not, who did?

PLEASE READ CAREFULLY
APPLICATION FORM WAIVER

In exchange for the consideration of my job application by Revenue Cycle Partners, LLC (hereinafter called “RCP”), I agree that:

Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other RCP practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of RCP, or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the Member(s) of RCP. Both the undersigned and RCP may end the employment relationship at any time, without specified notice or reason. If employed, I understand that RCP may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits.

I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give RCP permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release RCP from any liability as a result of such contract.

I understand that RCP has a confidentiality policy and that agreeing to adhere to that policy is a condition of my employment.

I also understand that (1) RCP has a drug and alcohol policy that provides for preemployment testing as well as testing after employment; (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy. I further understand that continued employment may be based on the successful passing of job-related physical examinations.

I understand that, in connection with the routine processing of your employment application, RCP may request from a consumer reporting agency an investigative consumer report including information as to my credit records, character, general reputation, personal characteristics, and mode of living. Upon written request from me, RCP will provide me with additional information concerning the nature and scope of any such report requested by it, as required by the Fair Credit Reporting Act.

I further understand that my employment with RCP shall be probationary for a period of ninety (90) days, and further that at any time during the probationary period or thereafter, my employment relation with RCP is terminable at will for any reason by either party.

Signature of applicant Date:

RCP is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with RCP depends solely on your qualifications.

Thank you for completing this application form and for your interest in our business.