Name
Program
Company Name
Employer Address
Start Date
End Date
Currently Employed Yes
Employer Phone Number
Supervisor's Name
Supervisor's Email
Your Position / Title
List of Job Duties (Please select all that apply) Customer ServiceData EntryClerical/ Office AssistingMedical BillingOffice ReceptionistMedical Front OfficeAdministrative Assistant DutiesBilling/Purchasing/InventoryShipping/ReceivingSpreadsheets/ReportsSecretarial DutiesMedical Data EntryAR/APKeyboardingAccounting dutiesBookkeeperCustomer Service/PaymentsGeneral OfficeSupplies Purchasing/Inventory
Hours Per Week
Wage
Signature
My Electronic signature certifies all the information above as true and correct to the best of my knowledge. Part Time/Temporary Work Statement: My electronic signature above indicates my choice to seek or accept part time work. Part time work is defined as at least 20 hours per week for 5 weeks (35 calendar days)
Today's Date
