On-Line Application

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CB ACCOUNTS, INC.
CB Accounts, Inc. is an Affiliate of
AHC Healthcare Receivables Management

On-Line Application

(Complete as much information as possible.)

Personal Information

First Name

Last Name

Middle Initial

Address

City

State

Zip

Phone

- -

Desired Employment

Collection Officer
Human Resources
Client Services
Information Systems
Operations
Patient Account Rep
Medical Insurance Follow-up
Other (please explain)

When can you start?

Now
1 Week
2 Weeks
Other (explain)

Are you employed now?

If so, may we contact your previous employer?

yes
no (explain)

Have you ever worked for our company?

Yes (When/Where)
No

How did you hear about us?

Referral (whom?)
Newspaper
Web Site
Other (explain)

Years attended school?

Employment History

Present/Last Employer
Address
Address (cont.)
City
State
Zip
Phone
Starting Date
Leaving Date
Job Title
Hourly Salary
Final Hourly Salary
Name of Supervisor
Title
Phone
Description of Work
Reason for Leaving

Employment History

Present/Last Employer

Address

Address (cont.)

City

State

Zip

Phone

Starting Date

Leaving Date

Job Title

Hourly Salary

Final Hourly Salary

Name of Supervisor

Title

Phone

Description of Work

Reason for Leaving

Employment History

Present/Last Employer
Address
Address (cont.)
City
State
Zip
Phone
Starting Date
Leaving Date
Job Title
Hourly Salary
Final Hourly Salary
Name of Supervisor
Title
Phone
Description of Work
Reason for Leaving

References
Name
Address
Relationship
Years Acquainted

Name
Address
Relationship
Years Acquainted

Name
Address
Relationship
Years Acquainted

Have you ever been convicted of a felony?

By checking the signature box below, I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.

Signature