Medical Management Services Incorporated

Application for Employment

Applications are accepted and employees are chosen for employment without regard to race, color, religion, sex, age, national origin, marital, citizenship or veteran status, disability or genetic information. Please complete all questions, leaving nothing blank. This application will be on file for 6 months. You may submit a new application if you wish to apply after that time. Please contact Human Resources at (757) 686-3500 if you need an accommodation to complete this application.
Applicant Information

 First Name      Middle Name Last Name      Maiden Name Email Address
   
Have you ever applied or submitted a resume to MMSI:        
Present Address   City   State   Zip Code   Country
       
Mailing Address Same as Present Address                
Mailing Address   City   State   Zip Code   Country
       
Home Phone Number    Work Phone Number 
  Phone Number for Messages 
 
     
If hired, can you provide proof that you are 18 years old or older:      If hired, can you provide proof that you are eligible to work in the United States:     
Have you ever worked for Medical Management Services Inc, NowCare Medical Center, Med-Systems Associates, Bayview Physicians:
 
Have you ever been employed by MMSI or any of its affiliates under a different name:
        
Do you have a relative working for MMSI or any of its affiliates under a different name:
 
   
How were you referred (Please Be Specific):
Have ever been convicted in a court of law to an offense other than a minor traffic violation:
 
Have you ever been involved in any federal or state investigations:
Have you ever been involved in any federal or state investigations concerning fraud and/or abuse:
Have you ever been or are you currently, excluded from providing services to patients that are covered under any federally funded health-care plan, including Medicaid, Medicare, & all other federal health-care programs:   
Has your professional license (nursing, x-ray, sleep, etc.) ever been voluntarily or involuntarily withdrawn, suspended, denied, revoked or restricted in any location?
Position(s) Applied For
First Choice: Second Choice: Desired Start Date: Desired Pay:  
 
Availability
Status:  
Work Days:
Desired Shift:

Education
School Name
From
mm/yyyy
To
mm/yyyy
Graduated
Type of Degree
Major
Minor
High School
   
Undergraduate College
Graduate College
Other
Please list any awards you have received in the last 10 years:
There may be a need to communicate with patients and others who do not speak English. 
If you are proficient in a language other than English, please complete the following. 
First Language:                               Second Language:                              
Do you: Do you:
Frequency of use: Frequency of Use:
Professional Registration, License Information (Must be completed if required by the position applied for )
  Registration Number Renewal Number Date Issued Date Expires Type
State
National
Specialized Training and/or Experience
Certifications:
(ACLS, CCRN, CPT, ect...)
Registration or Certification #
Date Issued
Expiration Date
Renewal #
Drivers License
Are you licensed to drive a car?    
Military Service
Do you have any experience from military service that would be relevant to the job(s) for which you are applying?  If yes explain in detail:
Professional Membership(s)
(Please exclude memberships which would reveal your, sex, race, religion, national origin, disability, or other protected status)

Record of Employment
List all employment for at least the last 10 years starting with the most recent position. 
Are you presently employed?
Company Name
Job Title Position
Reason and type of leaving
 
Street Address City State Zip Code Phone Job Duties
Supervisor's Name Supervisor's Title Dates Employed Start End Starting Pay Rate Ending Pay Rate
Company Name
Job Title Position
Reason and type of leaving
 
Street Address City State Zip Code Phone Job Duties
Supervisor's Name
Supervisor's Title
Dates Employed Start End
Starting Pay Rate Ending Pay Rate
Company Name
Job Title Position
Reason and type of leaving
   
 
Street Address City State Zip Code Phone Job Duties
Supervisor's Name
Supervisor's Title
Dates Employed Start End
Starting Pay Rate Ending Pay Rate
Company Name
Job Title Position
Reason and type of leaving
   
 
Street Address City State Zip Code Phone Job Duties
Supervisor's Name
Supervisor's Title
Dates Employed Start End
Starting Pay Rate Ending Pay Rate
Company Name
Job Title Position
Reason and type of leaving
   
 
Street Address City State Zip Code Phone Job Duties
Supervisor's Name
Supervisor's Title
Dates Employed Start End
Starting Pay Rate Ending Pay Rate
 
References

List two people who are not related to you and are not previous employers
  Name Address Telephone Occupation  
1
2
Personal References
Please list at least two people familiar with your technical ability that we may contact.  Please do not list relatives
 
1
2
3  
4  

READ CAREFULLY BEFORE SUBMITING

It is the goal of Medical Management Services, Inc.(MMSI) to employ the qualified individual who best matches the requirements for the position to be filled.  I certify that the statements herein are made truthfully without evasion and agree that the statements may be investigated and if found false may subject me to disqualification for employment or be sufficient reason for my dismissal.  MMSI reserves the right to make any investigation into my previous employment history, financial, credit or public records, including criminal background through investigative or credit agencies or bureaus of MMSI’s choice.  I authorize all schools which I attended and all previous employers to furnish to MMSI my record, reason for leaving and all information they may have concerning me and hereby release them and MMSI from all liability for any damage whatsoever arising there from.

I have read and agree to the above statement: 




4/20/2014 4:29:09 AM
Click Here To Report Error On Page