Acme Health Care
Employment Application
Applicant Information
Full Name: Brown
Last
Abigail
First
M
M.I.
Date: February 20, 2013
Address:
113 East Raleigh Street
Street Address Apartment/Unit #
Raleigh
City
NC
State
27614
ZIP Code
Phone:
(919) 562-9125
Email brownabigail@gmail.com
MondayDate Available: Thursday
Social Security No.: 251-98-0987
Desired Salary:$ 85,000
Position Applied for: Physician Assistant Are you a citizen of the United States? Have you ever worked for this company?
YES YES X YES NO YES NO
If no, are you authorized to work in the U.S.?
NO X NO X
If yes, when?
Have you ever been convicted of a felony? If yes, explain:
Education
High School: From: 2009 Rolesville High School To:2013 Address:1528 Forestville Road Did you graduate?
YES X NO
Diploma::
College: Meredith College
Address: 1500 Hillsborough Street
YES X NO
From: Other:
2013
To:2017
Did you graduate?
Bachelors of Science in Degree:Psychology
East Carolina University
Address:56 Greenville Avenue
YES X NO
From:
2017
To:2019
Did you graduate?
Masters in Physicians Degree:Assisting
References
Please list three professional references.
Full Name: Susan Bordwalk 1 Relationship: Former Employer
Company: Address:
Carolina Womens and Associates 900 St. Albans Drive Raleigh NC 27614 Suite 501
Phone:(919) 256-0091
Full Name: Braydan Wagstow Company: Address: Full Name: Company: Address: Lab Corporation 70 East Athens Drive Raleigh NC 27614
Relationship: Internship Supervisor Phone:(252) 980-1256
Relationship: Phone:
Previous Employment
Company: Address: Job Title: Carolina Womens Associates 900 St. Albans Drive Raleigh NC 27614 Suite 500 Office Manager Starting Salary:$ 14/hour Phone:(919) 256-0091 Supervisor:Dr. Starr J. Coop Ending Salary:$ 16/hour
Responsibilities: Scheduling, phone notes, faxing medications, phone calls, monthly budget From: October 2015 To: December 2017 Reason for Leaving: Graduate School preparation
YES X NO
May we contact your previous supervisor for a reference?
Company: Address: Job Title: Responsibilities: From: To: Reason for Leaving:
YES NO
Phone: Supervisor: Starting Salary:$ Ending Salary:$
May we contact your previous supervisor for a reference?
Company: Address: Job Title: Responsibilities: From: To: Reason for Leaving:
YES NO
Phone: Supervisor: Starting Salary:$ Ending Salary:$
May we contact your previous supervisor for a reference? 2
Military Service
Branch: Rank at Discharge: If other than honorable, explain: From: Type of Discharge: To:
Disclaimer and Signature
I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
Signature:
Abigail M. Brown
Date: February 20, 2013
