CVA Application for Employment

You may complete the following application online or forward your current resume to the attention of Mary Warren SPHR, Director of Human Resources, using one of the following methods

Email: mwarren@cvaky.com
Fax: 502-891-8668
Address: 6420 Dutchmans Lane, Suite 200 Louisville, KY 40205

Personal Information

Last Name:

First Name:

Middle Initial: A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Social Security Number: - -

Home Phone Number: - -

Other Phone Number: - -

Address:

Additional Address Info:

City:

State: AL AK AR AZ CA CO CT DE FL GA HI ID IL IN IA KS KY LA MA ME MD MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WY

Zip Code:

Email:

Position for which you are applying for: PLEASE SELECT A POSITION MEDICAL ASSISTANT

Have you ever been employed here before?: No Yes

Type of Employment Desired: Part-Time Full-Time

Date Available for Work: mm/dd/yyyy 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2007 2008 2009

What is your desired salary?:

Are you able to meet the attendance requirements of this position?: No Yes

Are you legally eligible for employment in the United States?: No Yes

Are you 18 years of age?: No Yes

Have you ever been convicted of a crime, including misdemeanors/traffic offense?:(Answering "Yes" to this question does not constitute an automatic disqualification of employment opportunity. The date of the offense and the seriousness and nature of violation are factors which will be considered.)

No Yes

Educational History

High School:

Name of School: City: State: AL AK AR AZ CA CO CT DE FL GA HI ID IL IN IA KS KY LA MA ME MD MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WY Course of Study:

Other:

Name of School: City: State: AL AK AR AZ CA CO CT DE FL GA HI ID IL IN IA KS KY LA MA ME MD MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WY Course of Study: Graduation Month and Year: January February March April May June July August September October November December 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 Highest Degree or Certification Received: Summarize any training, skills, licenses and/or certificates that may qualify you to perform the job-related functions of the position being applied for:

Work History

Provide the following information on your past four (4) employers, starting with the most recent.

Employer #1:

Address:

Addt'l Address Info:

City:

State: AL AK AR AZ CA CO CT DE FL GA HI ID IL IN IA KS KY LA MA ME MD MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WY

Zip Code:

Phone Number: - -

Ext.:

Supervisor's Name:

Salary:

Dates of Employment

From: (month/year) January February March April May June July August September October November December 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940

To: (month/year) January February March April May June July August September October November December 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940

May we contact for reference?: No Yes

Job Title:

Brief Description of Job Responsibilities:

Reason for Leaving (one sentence):

Employer #2:

Address:

Addt'l Address Info:

City:

State: AL AK AR AZ CA CO CT DE FL GA HI ID IL IN IA KS KY LA MA ME MD MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WY

Zip Code:

Phone Number: - -

Ext.:

Supervisor's Name:

Salary:

Dates of Employment

From: (month/year) January February March April May June July August September October November December 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940

To: (month/year) January February March April May June July August September October November December 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940

May we contact for reference?: No Yes

Job Title:

Brief Description of Job Responsibilities:

Reason for Leaving (one sentence):

Employer #3:

Address:

Addt'l Address Info:

City:

State: AL AK AR AZ CA CO CT DE FL GA HI ID IL IN IA KS KY LA MA ME MD MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WY

Zip Code:

Phone Number: - -

Ext.:

Supervisor's Name:

Salary:

Dates of Employment

From: (month/year) January February March April May June July August September October November December 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940

To: (month/year) January February March April May June July August September October November December 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940

May we contact for reference?: No Yes

Job Title:

Brief Description of Job Responsibilities:

Reason for Leaving (one sentence):

Employer #4:

Address:

Addt'l Address Info:

City:

State: AL AK AR AZ CA CO CT DE FL GA HI ID IL IN IA KS KY LA MA ME MD MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WY

Zip Code:

Phone Number: - -

Ext.:

Supervisor's Name:

Salary:

Dates of Employment

From: (month/year) January February March April May June July August September October November December 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940

To: (month/year) January February March April May June July August September October November December 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940

May we contact for reference?: No Yes

Job Title:

Brief Description of Job Responsibilities:

Reason for Leaving (one sentence):

Thank you for taking the time to complete an application for employment with Cardiovascular Associates. Your qualifications will be reviewed against current openings and we will contact you should there be a match to one of our positions. All on-line applications stay active for a period of 90 days. By submitting this application, I certify that the information in this application is correct to the best of my knowledge and I understand that deliberate falsification of information is grounds for refusal to hire or dismissal from employment. Cardiovascular Associates is an Equal Opportunity Employer.