Plexus Health Solutions, Inc. - Full Service Medical Billing

Consultation, Training, Practice Management, Medical Billing

PLEXUS HEALTH SOLUTIONS, INC.
700 57 ST
KENOSHA, WI 53141

Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation
to the application and/or interview process should notify a representative of the Human Resources Department.

Position(s) applied for Date of application

Last name First name Middle name Social Security #

Address City State Zip Code

Telephone # Mobile/Beeper/Other Phone # Email Address

If you are under 18, and it is required, can you furnish a work permit? (check if Yes)

If no, please explain

Have you ever been employed here before? (check if Yes) If Yes, give dates and positions

Are you legally eligible for employment in this country? (check if Yes)

Date available for work What is your desired salary range?

Type of employment desired

Type of work schedule interested in (check all that apply)	Days (1st Shift)	Evenings (2nd Shift)	Nights (3rd Shift)	Pool
	Weekends	Split Shifts	Rotating Shifts	Overtime

Are you able to meet the attendance requirements of the position? (check if Yes)

Have you ever pled "guilty" or "no contest" to, or been convicted of a crime? (check if Yes)
If yes, please provide date(s) and details
ANSWERING "YES" TO THESE QUESTIONS DOES NOT CONSTITUTE AN AUTOMATIC BAR TO EMPLOYMENT. FACTORS SUCH
AS DATE OF THE OFFENSE, SERIOUSNESS AND NATURE OF THE VIOLATION, REHABILITATION AND POSITION APPLIED FOR
WILL BE TAKEN INTO ACCOUNT.

Driver's license number if driving is an essential job function State

Employment History

Provide the following information of your past three (3) employers, assignments or volunteer activities, starting with the most recent.

FROM	TO	EMPLOYER	TELEPHONE #
STARTING JOB TITLE FINAL JOB TITLE		ADDRESS
IMMEDIATE SUPERVISOR AND TITLE		SUMMARIZE THE NATURE OF WORK PERFORMED AND JOB RESPONSIBILITIES
MAY WE CONTACT FOR REFERENCE?
REASON FOR LEAVING		HOURLY RATE/SALARY START $ PER FINAL $ PER

FROM	TO	EMPLOYER	TELEPHONE #
STARTING JOB TITLE FINAL JOB TITLE		ADDRESS
IMMEDIATE SUPERVISOR AND TITLE		SUMMARIZE THE NATURE OF WORK PERFORMED AND JOB RESPONSIBILITIES
MAY WE CONTACT FOR REFERENCE?
REASON FOR LEAVING		HOURLY RATE/SALARY START $ PER FINAL $ PER

FROM	TO	EMPLOYER	TELEPHONE #
STARTING JOB TITLE FINAL JOB TITLE		ADDRESS
IMMEDIATE SUPERVISOR AND TITLE		SUMMARIZE THE NATURE OF WORK PERFORMED AND JOB RESPONSIBILITIES
MAY WE CONTACT FOR REFERENCE?
REASON FOR LEAVING		HOURLY RATE/SALARY START $ PER FINAL $ PER

References

NAME	TELEPHONE	NUMBER OF YEARS KNOWN

Special/Related Training
List any special training that you've completed that may qualify you as being able to perform job-related functions
in the position for which you are applying:

Comment on any additional related experience(s) you may have had that may qualify you as being able to perform
job-related functions in the position for which you are applying. (For Example: Clinical Experience, Home health Care,
Urgent Care, Senior Care, Pharmacy, Voluntary Service, etc.):

License and Certification Information

List all applicable licenses or certifications that you have and their expiration dates below:
LICENSE/CERTIFICATION	# (IF APPLICABLE)	DATE ISSUED	EXP. DATE

Educational Background (if job related)

	NAME AND LOCATION	NUMBER OF YEARS COMPLETED	DID YOU GRADUATE?	COURSE OF STUDY
HIGH SCHOOL
COLLEGE			MAJOR DEGREE
OTHER

Applicant Statement

I certify that all information I have provided in order to apply for and secure work with the employer is true, complete and correct.

I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient
cause to (i) cancel further consideration of this application, or (ii) immediately discharge me from the employer's service, whenever it is
discovered.

I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all
references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify
the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may
have regarding the employer, its agents, employees or representatives, for seeking, gathering and using such information in the employment
process and all other persons, corporations or organizations for furnishing such information about me.

I understand that the employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of
limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state or federal law.

I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and
still wish to be considered for employment, it will be necessary to reapply and fill out a new application.

If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the
same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. this
application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no
supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied, oral or written
agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer's president.

I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that
federal immigration laws require me to complete an I-9 Form in this regard.

It is at the employer's discretion to run a criminal and/or financial background check and random drug tests.

DO NOT ELECTRONICALLY SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT

I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement by electronically signing with my
initials or name below.

You can attach up to 3 files below which can include a resume or other document(s):
(.doc or .pdf files are accepted)

Attach File1:

Attach File2:

Attach File3: