Application for Employment | Holistic Health Associates

Which Location Are You Applying For?(Required)

Frederick

Boonsboro

PERSONAL

Full Name (First + Middle + Last)(Required)

Date of Birth(Required)

Other name(s) under which you have been previously employed

Driver's License Number(Required)

Drivers License State(Required)

Drivers License Copy(Required)

Max. file size: 128 MB.

Permanent Address(Required)

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone(Required)

Email(Required)

Do you have a legal right to work in the U.S.?(Required)

Yes

Other name(s) under which you have previously been employed

Names of friends or relatives employed in this organization

Have you applied to this organization before?(Required)

Yes

If yes, give date and position applied for

Have you ever been employed by this organization before?(Required)

Yes

If yes, list dates of employment and position

Do you have any family, business, health, or social restrictions or obligations that would prevent you from performing the job responsibiilties?(Required)

Yes

Do you have any physical or mental condition or handicap which would endanger the health or safety of yourself and or others that may affect your ability to perform the job(s) for which you are applying?(Required)

Yes

If yes, list dates of employment and position

Have you ever been convicted of a felony?(Required)

Yes

If yes, list dates of offense, and disposition.

Convictions are not an automatic disqualification from employment.

Will you comply with the safety work and attendance policies of our organization?(Required)

Yes

Employment Interests

What position in the company are you applying for?(Required)

Front Desk Associate

Office Manager

Insurance

Acupuncturist

Massage Therapist

Reiki Practitioner

Other

Please list all modalities you are actively certified to offer?(Required)

Do you have a CAQH Profile?(Required)

Yes

Do you have an NPI number (National Provider Identification)?(Required)

Yes

All providers employed at HHA are required to obtain NPA numbers. Register for one at NPPES (hhs.gov).

Please enter your 10-digit NPI number

Date Available(Required)

Type of Employment You Are Seeking(Required)

Part Time (15-30 hours)

Full Time (30-40 hours)

Shifts You Can Work(Required)

Morning

Evening

Saturday

How will you get to work?(Required)

How were you referred to our organization?(Required)

Name of Referral Source:

In a few sentences please tell us what excited you about this opportunity and why do you want to work at Holistic Health Associates?(Required)

Education/U.S. Military Service

Where did you attend high school & college (Click the + button to add a new row)(Required)

School Name & Address

Major

Years Completed

GPA

Degree/Diploma

Are you taking any educational course(s) presently?(Required)

Yes

I will be soon

If yes or you will be soon, what and where?

Have you ever served in the U.S. Armed Services?(Required)

Yes

Other

US Military Duties and special training

Rank held at discharge

References

List 3-5 people we may contact who are qualified to evaluate your capabilities. Do not include relatives (Click the + button to add a new row)

Name

Address

Occupation

Years Known

Phone Number

Employment History

Give employment record as completely as possible, listing current or most recent employer first. Show unemployed or self-employed periods and indicate dates and comment on each period. Include part time or summer work.

Company Name (Most Recent)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Dates Employed

From

Job Title

Supervisors Name & Title

Type of Business

Business Website

Base Rate of Pay (Hour/Week/Month)

Start

End

Description of duties

Reason for Leaving?(Required)

May we contact this employer?(Required)

Yes

Did you have another job before this one?(Required)

Yes

Company Name (Second Most Recent)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Dated Employed

From

Job Title

Supervisors Name & Title

Type of Business

Website

Base Rate of Pay (Hour/Week/Month)

Start

End

Description of duties

Reason for leaving?

May we contact this employer?

Yes

Would you like to list another previous job? (third most recent)

Yes

Company Name (Third Choice)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Dated Employed

From

Job Title

Supervisors Name & Title

Type of Business

Business Website

Base Rate of Pay (Hour/Week/Month)

Start

End

Description of duties

Reason for leaving

May we contact this employer?

Yes

Would you like to list a 4th job?

Yes

Company Name (Fourth Most Recent)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Dates Employed

From

Job Title

Supervisors Name & Title

Type of Business

Business Website

Base Rate of Pay (Hour/Week/Month)

Start

End

Description of duties

Reason for leaving?

May we contact this employer?

Yes

I agree to a Drug Screening at the company expense(Required)

Yes

I agree to a Criminal Background Check at the company's expense(Required)

Yes

Acknowledgement

Digital Signature:(Required)

Printing your First Name + Middle Initial + Last Name will act as your digital signature.

Date(Required)

Resume Upload

Accepted file types: doc, docx, pages, odt, rtf, tex, txt, wpd, wps, pdf, Max. file size: 128 MB.

Please attach your resume here.

Would you like to add a cover letter?

Yes

Cover Letter (optional)

Accepted file types: doc, docx, pages, odt, rtf, tex, txt, wpd, wps, pdf, Max. file size: 128 MB.

Please upload your cover letter here. You may also copy and paste the contents of your cover letter in the space below.

Do you have your own Malpractice Insurance?

Yes

Malpractice Insurance Certificate

Accepted file types: doc, docx, pages, odt, rtf, tex, txt, wpd, wps, pdf, Max. file size: 128 MB.

If hired, are you interested in joining HHA's group policy or will you be getting your own?

I will join HHA’s group policy if hired

I will be acquiring my own Malpractice Insurance if hired