Personal Data

Last Name*

First Name*

Middle Name

Today's Date

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Home Phone*

Business Phone

Other

Did an employee of HME Specialists refer you?

Yes

No

Name

Are you at least 18 years of age?

Yes

No

Are any employees of HME Specialists related to you by blood or marriage?*

Yes

No

Name

Do you have the legal right to work in the United States?*

Yes

No

What languages do you speak?

POSITION APPLIED FOR

List, by title the position for which you wish to apply*

# of hours applying for*

Full time

Part time

Other

If the position you are applying for requires you to be on-call, can you work nights, weekends and holidays as necessary?*

Yes

No

EDUCATION

High School (GED)

List*

Name of School and Address

From Mo/Yr

To Mo/Yr

Did you Graduate?

Degree

Major

College Undergrad

List

Name and Address

From Mo/Yr

To Mo/Yr

Did you Graduate?

Degree

Major

College Graduate

List

Name and Address

From Mo/Yr

To Mo/Yr

Did you Graduate?

Degree

Major

Vocational Business

List

Name and Address

From Mo/Yr

To Mo/Yr

Did you Graduate?

Degree

Major

Military Schools

List

Name and Address

From Mo/Yr

To Mo/Yr

Did you Graduate?

Degree

Major

MILITARY HISTORY (OPTIONAL)

Are you currently in the military or a US Veteran?

Yes

No

Your name if different from present name

Branch of Service

Start Date of Service

End Date of Service

Rank Attained

Job Title

Briefly describe your specific duties

GENERAL INFORMATION

Have you ever been excluded, debarred, suspended or sanctioned from participating in any Federal or State health care related programs?

Yes

No

Are you able to perform the essential functions of the position(s) for which you have applied, with or without accommodation?

Yes

No

PROFESSIONAL REFERENCES

Name

Professional Relationship

Phone

Please list 3 professional references. Include name, professional relationship and phone number

NOTE: HME's policy could disqualify an applicant who has a certain criminal history from employment in particular positions. All positions are contingent on background and drug test.

Upload your resumé if available - drag and drop or click to choose file.

Max. file size: 2 MB.

CERTIFICATE OF APPLICANT

Permission is hereby granted to HME Specialists to conduct any necessary and reasonable investigation with respect to statements and other information in this application. I release HME Specialists, my former employers and personal references from any liability for damage caused by giving and receiving information or opinions as to my employment and character. I agree to furnish any other information required of me related to my employment. I also understand and agree that any false statements or any material misrepresentation of the information referred to above will be sufficient grounds for my separation. I understand the requirements and essential functions of the job(s) and certify that I am able to perform those job duties and functions. I have a genuine interest to be employed and no other purpose in submitting this application. I understand that this employment application will remain active for 120 calendar days, and that upon expiration of this application, to continue to be considered for employment, I must complete a new application.

Medicare Customer Service Representative

Personal Data

POSITION APPLIED FOR

EDUCATION

LICENSES & SPECIAL SKILLS

EMPLOYMENT HISTORY

MILITARY HISTORY (OPTIONAL)

GENERAL INFORMATION

CERTIFICATE OF APPLICANT

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