Todays Date: *
Position Desired: *
Shift preference: *
First, Middle and Last Name: *
E-Mail Address:
Address 1: *
Address 2:
City: *
State: *
Zip: *
Phone: *
Cell Phone:
Social Securty: *
Are you at least 18 years of age: *
Emergency Contact Name & Relation: *
Emergency Contact Phone: *
How did you hear about us:
License/Certification/Registration type, number and expiration date: *
List recent areas of experience (ie: Medical/Surgical, Office, etc.) include month and year:: *
Has your license, certification or registration ever been limited, suspended or revoked: *
If yes, please explain or if no put N/A: *
Have you ever been convicted of a felony: *
If yes, date of conviction if no put N/A: *

(A record of a conviction of a felony may not disqualify you from consideration for employment with this agency.)

Have you ever been convicted in a court of law of a crime involving abuse, neglect or mistreatment of an individual: *

(This question is made pursuant to the provisions of CFR 483.13(c) (l) (ii))

Do you have a valid State Driver’s License: *
If yes put expiration date, if no put N/A: *
Special Skills, Certifications, Qualifications: *
BLS expires : *
ACLS expires:
PALS expires:
NRP expires:
TNCC expires:
Instructor Certified:
EDUCATION: Please list school, full address, dates attended, graduation date and degree obtained.
High School: *
College or University:
EMPLOYMENT HISTORY: Date and place of employment, address, supervisiors name and phone, your job title and duties, hourly wage and reason for leaving.
Employment 1:: *
Employment 2:: *
Employment 3:: *
If you are currently employed, may we contact your employer: *
Recent work references (name, title, phone & address). List supervisors or others who have knowledge of your qualifications. Reference #1:: *


Reference #2:: *

Reference #3:: *

Initials: *


FALSIFICATION OF RECORDS: This application was completed by me and I certify that the information is correct to the best of my knowledge. I understand that falsification of this application or omission of requested information in any detail is grounds for disqualification from further consideration or for dismissal from employment.

EMPLOYMENT AT WILL: I will follow the policies and procedures of this agency as communicated to me. I understand that in no event shall my hiring be considered as creating a contractual relationship between myself and the agency, and unless otherwise provided in writing, such relationship shall be defined as “employment at will,” where either party may dissolve the relationship at any time, for any reason, with or without cause. I further understand that no employee, supervisor or manager except the Owner or Administrator has the authority to enter into any agreement or contract of employment for any specific terms of employment such as length of service, future salary increases, or agreement contrary to this application. Furthermore, I understand that any such agreement entered into will not be enforceable unless it is in writing.

CONDITIONAL OFFER OF EMPLOYMENT: If I receive a conditional offer of employment, I understand that I may be the subject of drug screening, criminal background study, and/or physical screening and evaluation, and I hereby consent to such screening and record checks.

PROOF OF RIGHT TO WORK: If I am offered a position with the agency, I understand that as a condition of employment I will be required to prove identity and right to work as required by the Immigration Reform and Control Act of 1986.

RELEASE OF INFORMATION: I acknowledge that consideration for employment is contingent on the results of a reference and background check. Therefore, I hereby authorize the agency to (1) investigate the truthfulness of all statements made on this application; (2) contact my former employers and other listed references or any other persons who can verify information; and (3) discuss the results of any investigation with other employees of the agency involved in the hiring process. In addition, I give my consent for all contacted persons including former employers to provide information concerning this application, and I release each such person from liability for providing information to the agency.

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