Apply for Medical Case Manager

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Summary
Title:Medical Case Manager
ID:1767
Department:HIV/AIDS
Employment Type:Full Time
Pay Rate:$18.00 per hour
Location:Baton Rouge, LA
Education:4 Year Degree
Experience:1-3 Years
Licensure:N/A
Contact Information
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Application for Employment
PERSONAL INFORMATION
* Are you legally eligible to be employed in the United States? (Proof of identity and eligibility will be required upon employment):
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* Are you at least 18 years or older? (If no, you may be required to provide authorization to work):
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* Have you ever been convicted of a felony or a misdemeanor which resulted in imprisonment within the last seven years? (A conviction will not necessarily result in the denial of employment):
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If Yes, please explain:
* Have you ever worked for this Company before?:
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If Yes, please provide details (Where/When/Job Title):
* Are you able to perform the essential functions of the job for which you are applying, with or without a reasonable accommodation?:
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EMPLOYMENT DESIRED
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Part Time
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* Are you currently employed?:
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If so may we inquire of your present employer?:
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If presently employed, why are you considering leaving?:

EDUCATION
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School Name & Location Did you Graduate? Degree Received Subjects Studied/Major
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If you have completed any special courses, seminars and/or training that would help you to perform the position for which you are applying, please describe:

EMPLOYMENT HISTORY
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EMPLOYER 1

Dates Employed Employer Name & Address Employer Phone
From:
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To:
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*
*
Job Title Supervisor Name & Title May we Contact?
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*

*
Yes
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Responsibilities Reason for Leaving Salary/Hourly Rate
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*
Start:
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End:
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EMPLOYER 2

Dates Employed Employer Name & Address Employer Phone
From:

To:

Job Title Supervisor Name & Title May we Contact?

Yes
No
Responsibilities Reason for Leaving Salary/Hourly Rate
Start:

End:

EMPLOYER 3

Dates Employed Employer Name & Address Employer Phone
From:

To:

Job Title Supervisor Name & Title May we Contact?

Yes
No
Responsibilities Reason for Leaving Salary/Hourly Rate
Start:

End:

REFERENCES Please provide three references (not relatives).

Name Relationship Phone Number Email

AUTHORIZATION
The facts set forth in this application and any supplemental information are true and complete to the best of my knowledge. I understand that, if employed, falsified statements on this application shall be considered sufficient cause for immediate discharge. I hereby authorize investigation of all statements contained herein and employers listed above to give you any and all information concerning my employment, and any pertinent information they may have, and release all parties from all liability for any damage that may result from furnishing same.

I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for the company to hire me. If I am hired, I understand that either the company or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of the company has the authority to make any assurance to the contrary.

I understand that I am required to abide by all rules and regulations of the company.

* Signature (type name):
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2023 - Voluntary Self-Identification of Disability CC-305

Voluntary Self-Identification of Disability

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