Job Application: Patient Advocate

Title: Patient Advocate

Fields marked with an asterisk (*) must be filled out before submitting.

Personal Details

First Name *
Last Name *
Email *
Phone *
Who Referred You?
Present Address *
City *
State *
Postal Code *


Date you can start
Your Desired Salary
Are you related to a current Utah Cancer Specialists employee? Yes
If you are currently employed, may we call your present employer for a reference? Yes
Have you applied to this organization before? Yes
If so, When?
Are you legally authorized to work in the United States? Yes
Have you been convicted of any crime(other then minor traffic violations) during the last seven years? (A criminal record does not automatically bar employment.) Yes
If Yes briefly state circumstances below
Are you capable of performing, with or without a reasonable accomodation, the essential function of the job or occupation for which you have applied? Yes
Do you have a current Drivers License? Yes
Attach Resume


Name of School *
School City *
State *
Type *
Years Completed *
Did you Graduate? *
Diploma/Degree *

Work History

Job Experience 1

Employer Name *
Street Address *
City *
State *
Position/Job Title *
Starting Salary/ Hourly Wage *
Final Salary/ Hourly Wage *
Specific duties *
Hours worked per week *
Beginning date of employment *
Ending date of employment (Leave Blank if Current)
Number of employees you supervised *
Your supervisor\\\\\\\\\\\\\\\’s name *
Your supervisor\\\\\\\\\\\\\\\’s phone number *
Reason for leaving or considering change *


Applicant Statement Terms and Agreement

Utah Cancer Specialists is an Equal Employment Opportunity/ Affirmative Action Employer. All employees and applicants for employment are extended fair and equal employment opportunities without regard to race, creed, color, religion, national origin, age, sex, disability, veteran, current or future military status. Utah Cancer Specialists is an at-will employer. An at-will employment relationship means employment may be terminated at the will of either the employee or UCS at any time, with or without cause, and with or without notice. Utah Cancer Specialists is a drug free/alcohol free/smoke free employer. Employment is contingent upon pre-employment drug testing.


This Employment Application is used to notify me that the nature and scope of an investigation, if one is conducted, could include such general identification information as residence verification, and, as applicable, information concerning my employment, education, general reputation, character, personal characteristics, and habits, and that such information may be developed through personal interviews with third parties such as family member, neighbors, friends, associates, former employers, financial sources, and custodians of official records. Only job-related information developed from such a report will be considered in evaluating my employment application or continued employment. I hereby authorize these persons or companies to answer all questions or release any information regarding the items listed in this paragraph. I hereby release them from any liability from any claim for releasing any truthful information within their knowledge and/or records. I understand that misrepresentation or omission of facts will result in dismissal. Further, I understand and agree that my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without prior notice, and without cause. I authorize the Company to release to any person, firm, entity or organization with which I may seek employment in the future, any truthful information concerning my work experience with the Company. I hereby release and hold the Company harmless from any claim for releasing any truthful information within its knowledge. I have had an opportunity to have my questions about this statement’s content and intent answered and I understand its terms.

* Checking this box constitutes your agreement to the Applicant\’s Statement above.

Review Your Application

* Checking this box constitutes you have verified your information above.