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