NATIONAL MD BILLING

Training & Internship Application

Applicant Information
Last Name First Name M.I.

Street Address Apartment/Unit City

State Zip Phone

Are you a citizen of the United States? YES NO If no, are you authorized to work in the U.S.? YES NO

Have you ever worked for this company? YES NO If so, when?

Have you ever been convicted of a felony? YES NO If yes, explain

Education
High School Address

From To Did you graduate? YES NO Degree

College Address

From To Did you graduate? YES NO Degree

Other Address

From To Did you graduate? YES NO Degree

References
Please list three references (personal and/or professional).

Full Name Relationship

Company Phone

Address

Full Name Relationship

Company Phone

Address

Full Name Relationship

Company Phone

Address
NATIONAL MD BILLING
Training & Internship Application

Employment History
Company Address

Phone Supervisor

Job Title Starting Salary Ending Salary

From To May we contact your previous supervisor for a reference? YES NO

Responsibilities

Reason for
Leaving

Company Address

Phone Supervisor

Job Title Starting Salary Ending Salary

From To May we contact your previous supervisor for a reference? YES NO

Responsibilities

Reason for
Leaving

Company Address

Phone Supervisor

Job Title Starting Salary Ending Salary

From To May we contact your previous supervisor for a reference? YES NO

Responsibilities

Reason for
Leaving

Company Address

Phone Supervisor

Job Title Starting Salary Ending Salary

From To May we contact your previous supervisor for a reference? YES NO

Responsibilities

Reason for
Leaving
NATIONAL MD BILLING
Training & Internship Application

Maryland Tech Connection (MTC)

Are you currently employed? YES NO If no, last date of employment

Are you currently receiving UI benefits? YES NO If yes, are they exhausted / completed? YES NO

Did your salary decrease anytime along the

Do you believe you are underemployed? YES NO YES NO
way since 2007?
Why do you feel you are unable to find
employment in your industry?
Annual household
Do you have income? YES NO Household size?
income?

How many dependents do you have? Do you have any child care concerns? YES NO

Do you have private

Do you use public transportation? YES NO YES NO
transportation?

Do you have issues purchasing gas? YES NO

Do you have a criminal history that would

YES NO NOT SURE
interfere with gaining employment?

Do you have a disability that would

YES NO NOT SURE
prevent you from gaining employment?

How would you rate your computer

Advanced Intermediate Basic
literacy?

How would you rate your English skills? Fluent Average Below Average

Disclaimer & Signature

By clicking the submit button, I certify that my answers are true and complete to the best of my knowledge.

If this application leads to an internship position with National MD Billing, I understand that false or misleading information in my application
or interview may result in my release.