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    National Billing: Please List Three References (Personal And/or Professional)

    Uploaded by

    Anonymous msT2iHOg
    The document appears to be an application for a training and internship program at National MD Billing. It requests information such as contact details, citizenship and authorization to work status, education history, references, employment history, Maryland Tech Connection information, computer and English language skills, and includes a disclaimer about the truthfulness of the application. The applicant is asked to provide their personal information, education credentials, work experience, references, and answer questions to determine their eligibility for the training program.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    National Billing: Please List Three References (Personal And/or Professional)

    Uploaded by

    Anonymous msT2iHOg
    15 views3 pages
    The document appears to be an application for a training and internship program at National MD Billing. It requests information such as contact details, citizenship and authorization to work status, education history, references, employment history, Maryland Tech Connection information, computer and English language skills, and includes a disclaimer about the truthfulness of the application. The applicant is asked to provide their personal information, education credentials, work experience, references, and answer questions to determine their eligibility for the training program.

    Original Description:

    test

    Original Title

    internship

    Copyright

    © © All Rights Reserved

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    The document appears to be an application for a training and internship program at National MD Billing. It requests information such as contact details, citizenship and authorization to work status, education history, references, employment history, Maryland Tech Connection information, computer and English language skills, and includes a disclaimer about the truthfulness of the application. The applicant is asked to provide their personal information, education credentials, work experience, references, and answer questions to determine their eligibility for the training program.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    15 views3 pages

    National Billing: Please List Three References (Personal And/or Professional)

    Uploaded by

    Anonymous msT2iHOg
    The document appears to be an application for a training and internship program at National MD Billing. It requests information such as contact details, citizenship and authorization to work status, education history, references, employment history, Maryland Tech Connection information, computer and English language skills, and includes a disclaimer about the truthfulness of the application. The applicant is asked to provide their personal information, education credentials, work experience, references, and answer questions to determine their eligibility for the training program.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 3

    NATIONAL MD BILLING

    Training & Internship Application

    Applicant Information
    Last Name First Name M.I.

    Street Address Apartment/Unit City

    State Zip Phone

    Are you a citizen of the United States? YES NO If no, are you authorized to work in the U.S.? YES NO

    Have you ever worked for this company? YES NO If so, when?

    Have you ever been convicted of a felony? YES NO If yes, explain

    Education
    High School Address

    From To Did you graduate? YES NO Degree

    College Address

    From To Did you graduate? YES NO Degree

    Other Address

    From To Did you graduate? YES NO Degree

    References
    Please list three references (personal and/or professional).

    Full Name Relationship

    Company Phone

    Address

    Full Name Relationship

    Company Phone

    Address

    Full Name Relationship

    Company Phone

    Address
    NATIONAL MD BILLING
    Training & Internship Application

    Employment History
    Company Address

    Phone Supervisor

    Job Title Starting Salary Ending Salary

    From To May we contact your previous supervisor for a reference? YES NO

    Responsibilities

    Reason for
    Leaving

    Company Address

    Phone Supervisor

    Job Title Starting Salary Ending Salary

    From To May we contact your previous supervisor for a reference? YES NO

    Responsibilities

    Reason for
    Leaving

    Company Address

    Phone Supervisor

    Job Title Starting Salary Ending Salary

    From To May we contact your previous supervisor for a reference? YES NO

    Responsibilities

    Reason for
    Leaving

    Company Address

    Phone Supervisor

    Job Title Starting Salary Ending Salary

    From To May we contact your previous supervisor for a reference? YES NO

    Responsibilities

    Reason for
    Leaving
    NATIONAL MD BILLING
    Training & Internship Application

    Maryland Tech Connection (MTC)


    Are you currently employed? YES NO If no, last date of employment

    Are you currently receiving UI benefits? YES NO If yes, are they exhausted / completed? YES NO

    Did your salary decrease anytime along the


    Do you believe you are underemployed? YES NO YES NO
    way since 2007?
    Why do you feel you are unable to find
    employment in your industry?
    Annual household
    Do you have income? YES NO Household size?
    income?

    How many dependents do you have? Do you have any child care concerns? YES NO

    Do you have private


    Do you use public transportation? YES NO YES NO
    transportation?

    Do you have issues purchasing gas? YES NO

    Do you have a criminal history that would


    YES NO NOT SURE
    interfere with gaining employment?

    Do you have a disability that would


    YES NO NOT SURE
    prevent you from gaining employment?

    How would you rate your computer


    Advanced Intermediate Basic
    literacy?

    How would you rate your English skills? Fluent Average Below Average

    Disclaimer & Signature


    By clicking the submit button, I certify that my answers are true and complete to the best of my knowledge.

    If this application leads to an internship position with National MD Billing, I understand that false or misleading information in my application
    or interview may result in my release.

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