Worker Registration: Medical Assistants

* required field

CONTACT INFORMATION

First Name *

Last Name *

Prefix *

Email *

Home Phone *

Cell Phone

Other/Work Phone

Fax Number

Address

Address 2 (Unit#, Apartment #, etc)

City *

State *

Zip Code *

County

Gender

Male Female

Birth Date if under 18

How did you hear about us? *

EMERGENCY CONTACT

Emergency Contact 1 Name

Emergency Contact 1 Phone

Emergency Contact 2 Name

Emergency Contact 2 Phone

PROFESSIONAL DETAILS

Professional Training Level *

Type of License/Certification *

State Licenses *
(select all that apply)

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana

Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

States you are applying to work in *
(select all that apply)

Arizona Arkansas California Colorado Florida Louisiana

Nevada New Mexico Oklahoma Texas Utah

Work Setting Preferences *
(select all that apply)

Retail Corporate Community Assisted Living

Preferred Shifts/Hours *

9:30AM - 3:30PM 9:30AM - 5:30PM 7:00AM - 1:00PM 12:00PM - 5:00PM

Days of General Availability *

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Specify the anticipated number
of hours per week *

Specify the anticipated number
of days per week *

Mass Immunizations Experience *

Type of Mass Immunizations Experience *

Average number of immunizations
provided per clinic *

Management Experience *

Yes No

Current Work Status *

Do you have your own vehicle to travel
to varying work sites? *

Yes No

How far are you willing to travel? *

Would any of your friends or colleagues be interested in working for Mollen Immunization Clinics? *

REFERENCES

Reference Name 1

Reference Relationship

Referenced Phone Number

Reference Email

Reference Name 2

Reference Relationship

Reference Phone Number

Reference Email

GENERAL INFORMATION

Preferred Employment Status

Preferred Employment Duration

First Availability

Do you have access to both a computer
and email? *
This will be our primary method of
communicating our scheduling and messaging.

Yes No

Fluent Languages *
(select all that apply)

English Spanish Other

Fluent Languages Other

Additional Comments

Releases & Acknowledgements *

NO PERSON SHALL BE DENIED EMPLOYMENT ON THE BASIS OF RACE, COLOR, ETHNICITY, NATIONAL ORIGIN, SEX/GENDER, SEXUAL ORIENTATION, RELIGION, CREED, DISABILITY (INCLUDING HIV STATUS, AGE, VETERAN STATUS, MARITAL STATUS, OR EX-OFFENDER STATUS.) Employment is contingent upon furnishing evidence of identity and employment eligibility. This employer participates in E-Verify, a service provided by the SSA and DHS to confirm work authorization by verifying Form I-9 documentation with the USCIS. I have read and understand the above
Yes *
I hereby authorize investigation of all statements contained in this application and on my resume, if provided. I certify that such statements are true, and understand that misrepresentation or omission of facts called for in this form, or on any resume provided by me, is cause for termination of employment without notice. I have read and understand the above
Yes *

Thank you for your interest!

Mollen Immunization Clinics, LLC
8328 E. Hartford Drive, Scottsdale, AZ 85255
Phone: 480-214-2000 website: www.FluShotsUSA.com