Employment Application

Applicant Information

Full Name: Davidson Brandy Date:06/21/24

Last First M.I.

Address: 2870 North Rocky Branch RD

Street Address Apartment/Unit #

Oneida KY 40972
City State ZIP Code
Phone: (606)619-5395 Emailbrandymarie26@outlook.com

Date Available: 06/22/24 Social Security No.:407-43-1576 Desired Salary:$16.00

Position Applied for: Medical Assistant Date of Birth: 05/29/1992

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

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

Are you or have you ever been on the Federal or State Medicare and/or Medicaid Ineligible List?
YES NO

☐ ☐ If yes, explain: ________________________________________________________________

Education

High School: Clay County High School Address: Manchester KY, 40962
YES NO
From: To: Did you graduate? ☐ ☐ Diploma:: Yes GPA: 3.8
2008 2011

College: Address:

YES NO
From: To: Did you graduate? ☐ ☐ Degree: GPA:

Other: Address:

YES NO
From: To: Did you graduate? ☐ ☐ Degree: GPA:

1
 References
Please list three supervisor references in chronological order (not coworkers, family or friends)

Full Name: Joseph Reed Relationship:Supervisor

Company: Dynata Phone:(606)645-4289
Address: Remote

Full Name: Heather Smith Relationship:Supervisor

Company: Manchester Memorial Hospital Phone:(606)557-7738
Address: Manchester KY, 40962

Full Name: Jason Gay Relationship: Supervisor

Company: Booneville Family Dentistry Phone: (606) 593-5100
Address: Booneville KY, 41314

Previous Employment

(Please list previous employment in chronological order)

Company: Dynata Phone: (606)645-4289

Address: Remote Work From Home Supervisor: Joseph Reed

Job Title: Telephone Interviewer Starting Salary: $10.00 Ending Salary: $10.00

Conducted Telephone Interviews, Utilizing strong communication, active listening, and

problem solving skills. Effectively Addressed concerns and inquiries. Accurately recorded
Responsibilities: information and maintained professionalism in high pressure situations.

From: 2022 To: 2024 Reason for Leaving:

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

Company: Manchester Memorial Hospital Phone: (606)557-7738

Address: Manchester KY, 40962 Supervisor: Heather Smith

Job Title: ER Registration Starting Salary:$13.00 Ending Salary: $13.00

Updated and maintained patient records, Collected and Verified patient demographics and
insurance information,Scheduled appointments, Collected Copays and deductibles, and
maintained a clean work area, following HIPAA regulations to protect patient privacy,
Responsibilities: Registered patients for labs, surgeries, and radiology.

From: 2018 To: 2021 Reason for Leaving: Sickness

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

2
Company: Boonville Family Dentistry Phone: (606) 593-5100
Address: Booneville KY , 41314 Supervisor: Jason Gay

Dental Assistant / Office

Job Title: Manager Starting Salary: $9.00 Ending Salary: $15.00

Successfully managed day-to-day operations of the office, ensuring smooth workflow and
optimal efficiency, Handled patient inquiries and concerns, ensuring a positive patient
Responsibilities: experience, Scheduled patient appointments, and handled all finances.

From: 2011 To:2017 Reason for Leaving:

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

Military Service

Branch: From: To:

Rank at Discharge: Type of Discharge:

If other than honorable, explain:

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge. I further authorize Advanced
Molecular Diagnostics to conduct a Background Check through a third party.
If this application leads to employment, I understand that false or misleading information in my application or
interview may result in my release.

Signature: Date: