Customer Service Rep Application Form

Care Managers and Representatives

Please complete the application form below for Care Managers and Representatives. Our team will review and vet it and get back to you as soon as possible.

Requirements:
- Registered Nurse
- Customer Service Background
- Administration Experience would be an asset
Name:*

First NameLast Name
Birth Date

MonthDayYear
Phone Number:*

Area CodePhone Number
E-mail Address:
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do You Have a Criminal record
Upload Police Certificate of Character:

Upload a File

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Are you a?*

Registered NurseGeneral NurseOther
Additional Skills That you may possess , Do you have?

Accounting ExperienceReceptionist ExperienceCustomer Service ExperienceOther (please specify)Marketing Experience
Others:
Describe your skills or qualifications:*
Upload Resume:

Upload a File

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Training or Certifications:
References Please list two (2) references that are familiar with your work life.
Reference 1
Name:*

First NameLast Name
Phone Number*

Area CodePhone Number
Years Known:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Reference 2
Name:*

First NameLast Name
Phone Number*

Area CodePhone Number
Years Known:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Should be Empty: