<p> SCRIBE EMPLOYMENT APPLICATION</p><p>Name: Last, First Today’s Date:</p><p>Address: Street City State Zip</p><p>Contact info: Home Phone Cell Phone E-mail</p><p>No. of years Education: School name, location, year graduated completed Course of study GPA High School</p><p>College</p><p>Post Graduate School:</p><p>Do you plan to apply to a graduate school program (medical school, PA school, etc.)? If so, when (month/year) do you hope to start classes?</p><p>When would you like to start working as a scribe?</p><p>WORK EXPERIENCE: You must complete this section even if attaching a resume. Start with your current or most recent position, and account for all periods of employment (including full-time, part-time, and temporary) for the previous five years. Use additional pages if necessary. Fm: Mo / yr To: Mo / yr Starting salary: 1 Company: Final salary:</p><p>Address: May we contact your supervisor? Yes No Full-time Part-time Position: Supervisor’s name: Reason for leaving:</p><p>Duties: EXPLANATION: Phone number:</p><p>Fm: Mo / yr To: Mo / yr Starting salary: 2 Company: Final salary:</p><p>Address: May we contact your supervisor? Yes No Full-time Part-time Position: Supervisor’s name: Reason for leaving:</p><p>Duties: EXPLANATION: Phone number:</p><p>Fm: Mo / yr To: Mo / yr Starting salary: 3 Company: Final salary:</p><p>Address: May we contact your supervisor? Yes No Full-time Part-time Position: Supervisor’s name: Reason for leaving:</p><p>Duties: EXPLANATION: Phone number: EMPLOYMENT APPLICATION</p><p>References #1</p><p>Name: </p><p>Address:</p><p>Phone Number:</p><p>Relationship:</p><p>Permission to Contact:</p><p>#2</p><p>Name: </p><p>Address:</p><p>Phone Number:</p><p>Relationship:</p><p>Permission to Contact:</p><p>#3</p><p>Name: </p><p>Address:</p><p>Phone Number:</p><p>Relationship:</p><p>Permission to Contact: EMPLOYMENT APPLICATION</p><p>Questions: Why do you want to be a scribe?</p><p>What qualities and experiences do you possess that make you a competitive candidate?</p><p>What previous experience do you have in the medical field?</p><p>Are you comfortable using computers? What is your average typing speed (words per minute)?</p><p>How many hours per week would you like to work?</p><p>Do you have schedule restrictions?</p><p>If you are not chosen in this round, would you like to be considered in the future for a position as a scribe?</p>