EMPOLYEE APPLICATION BUILD YOUR PROFILE First Name * First Name is required Middle Initial Last Name * Last Name is required E-Mail * E-Mail is required Phone # * Phone# is required Please list any other names that you may go by Any other names is required Home Address * Home Address is required Are you licensed/certified for the job applied for? * Yes No Licensed/Certified is required Name of License/Certification * Name of License/Certification is required Issuing State * Issuing State is required License/Certification# * License/Certification Number is required Name of License/Certification * Name of License/Certification is required Issuing State * Issuing State is required License/Certification# * License/Certification Number is required Add another License/Certification Has your License/Certification ever been revoked or suspended? * Yes No Licensed/Certified Suspension is required If YES, please provide an explanation below. The reason is required Certifications * BLS Active? Yes No {{acert.BLS}} On Please place a check in the box next to each Certification. ACLS Active? Yes No {{acert.ACLS}} On Please place a check in the box next to each Certification Remove Above Certification PALS Active? Yes No {{acert.PALS}} On Please place a check in the box next to each Certification Remove Above Certification NRP Active? Yes No {{acert.NRP}} On Please place a check in the box next to each Certification Remove Above Certification NIHSS Active? Yes No {{acert.NIHSS}} On Please place a check in the box next to each Certification Remove Above Certification Add More Certifications ACLS PALS NRP NIHSS Please list any additional certifications not already specified above? College Graduated From * College Graduated From is required Month / Year * Month / Year is required College Address * College Address is required College Degrees * ASN BSN MSN Allied/OtherOther college degree text field is required Please select an option above Do you have additional education to add? * Yes No Please select an option for 'additional education to add' If YES, please specify additional educations. Please specify additional educations Specialty/Unit * Nursing - Certified Nursing Assistant Nursing - Critical/Intensive Care Nursing - Dialysis Nursing - Labor & Delivery Nursing - Postpartum/Newborn Nursery Nursing - Licensed Vocational Nurse Nursing - Medical Surgical Nursing - Neonatal Intensive Care Nursing - Operating Room Nursing - Pediatric Intensive Care Nursing - Post Anesthesia Care Unit Nursing - Psychiatric Nursing - Telemetry Nursing - Stepdown Nursing - Emergency Room Nursing - Case Manager Nursing - Home Health Allied - Anesthesia Tech Allied - Certified Occupational Therapist Assistant Allied - EEG Tech Allied - ER Tech Allied - Endoscopy Tech Allied - Mammography Tech Allied - Medical Assistant Allied - Occupational Therapist Allied - Pharmacist Allied - Pharmacy Tech Allied - Phlebotomist Allied - Physical Therapist Assistant Allied - Physical Therapist Allied - Cath Lab Tech Allied - CT Tech Allied - MRI Tech Allied - Nuclear Medicine Tech Allied - Radiation Therapy Tech Allied - Radiology Tech Allied - Respiratory Therapist/Dosimetrist Allied - Speech Language Pathologist/ Speech Therapist Allied - Echo Vascular Tech Allied - Echocardiography Tech Allied - Ultrasound Tech Allied - Vascular Tech Allied - Sterile / Central Service Tech Allied - Surgical Tech/ OR Tech Allied - Tele/Monitor Tech Allied - EKG-ECG Tech Allied - Medical Technologist/Clinical Lab Scientist Unit Speciality is required Years of experience * Years of experience is required Shift Preference * Days Nights Any Please select an option above Job Type * Travel Per Diem Both Please select an option above Available Start Date * Available Start Date is required Any time off? Any Time Off is required Who is your recruiter? * Jackie Pham Cesar Munor Eric McClelland Ryan Schneider Fabian Lopez Jamie Armstead Cindy Nguyen Christine Horn Other I don't have a recruiter Who Recruiter is required Next How strong are your skills? SELECT THE SKILLS THAT YOU HAVE. YOU NEED TO HAVE WORKED AT LEAST 1 FULL YEAR IN THE SELECTED POSITION. DIALYSIS ER CASE MANAGER HOME HEALTH ICU L&D/PP TELE MED SURG NICU OR PACU PEDS PICU PSYCH Next How strong are your skills? SELECT THE SKILLS THAT YOU HAVE. YOU NEED TO HAVE WORKED AT LEAST 1 FULL YEAR IN THE SELECTED POSITION. LVN ECHO CARDIOLOGY VASCULAR ECHO VASCULAR ULTRA SOUND XRAYTECH RADIAION THERAPY SPECIAL PROCEDURES NUCLEAR MEDININE CATHLAB MRI TECH CT TECH Next {{healthcare.step1.UnitSpeciality }} The checklist is meant to serve as general guideline for our client facilities as to the level of your skills within your speciality. Please use the scale below to describe your experience/expertise in each area listed below. 1. Never Performed 2 = Limited Experience 3 = Comfortable Performing 4 = Proficient {{basicnursing}} 1 2 3 4 {{skill_key}} Back Next Tell us where you have worked You will need to choose 2 employers from your work history as references. References need to equal up to 1 year of employment. Do not list staffing agencies only hospitals/facilities Employer Name ({{value}}) * Employer Name is required Employer Phone# ({{value}}) * Employer Phone is required Employer Address ({{value}}) * Employer Address is required Start Date ({{value}}) * End Date ({{value}}) * Current Employeer ({{value}}) * Yes No Both Employments Dates are required! Position/Title/Unit ({{value}}) * Position/Title/Unit field is required Would you like to use this employer as a reference? ({{value}}) * Yes No Employer Reference is required Manager/ Supervisor or Charge Nurse Name ({{value}}) * Manager/Supervisor or Charge Nurse Name is required Phone# ({{value}}) Manager/Supervisor or Charge Nurse Phone# is required Do you have another reference for this employer? ({{value}}) * Yes No Please select the option for "Employer Another Reference" is required Manager/ Supervisor or Charge Nurse Name ({{value}}) * Another Manager/Supervisor or Charge Nurse Name is required Phone# ({{value}}) Another Manager/Supervisor or Charge Nurse Phone# is required Do you have more work experiece to add? ({{value}}) * Yes No Working Experrience? is required Minimum 2 Required Please fill all fields above Back Next Important Part Social Security Number * Social Security Number is required Date of Birth * Date of Birth is required Home Address * Home Address is required Are you licensed/certified for the job applied for? * Yes No Licensed/Certified is required Name of License/Certification * Name of License/Certification is required Issuing State * Issuing State is required License/Certification# * License/Certification Number is required Name of License/Certification * Name of License/Certification is required Issuing State * Issuing State is required License/Certification# * License/Certification Number is required Add another License/Certification Has your License/Certification ever been revoked or suspended? * Yes No Licensed/Certified Suspension is required Please list any additional certifications not already specified above? The disciplinary action field is required Upload Resume Resume is required Next Just a few more questions 1) Are you at least 18 years or older? * Please select Yes or No Yes No 2) Any gap in Employment for more that 30 days? * If YES, please explain any gap in Employment for more that 30 days The descripion is required Please select Yes or No Yes No 5) If hired, can you present evidence of your eligibility to work in United States? * Please select Yes or No Yes No Back Next Let's wrap this up Applicant's Statement (Initial each numbered item as read) 1) I certfify that all the informaiton I have given on this application is true and complete and that I have not knowlingly withheld any information that might adversely affect my chances for employment. I understand that failure to provide complete information or any misrepresentation in the information I provide whether on this for or otherwise may lead to refusal to hire me to termination of employment. * Please select the option 2) I authorize inquiry into any suitability for the position for which I am being considerred and I hereby give my consent to present and past employers to release the informaation necessary to verify my work history and hereby release my present and past employers from all liability for any demages whatsoever arising for th release of any and all information regarding my employment. * Please select the option 3) I understand that there is no offter of an employment contract or guarantee of lenght of employment and that I should be hired my employment and compensation can be terminated, with or without notification or cause, at any time, at the option of either the firm or myself. I understand that no employee or other representative of the firm is authorized to make any other representation to employees regarding the term of my employment. And I confirm that no other representation has been made to me. * Please select the option 4) In compliance with Federal Law, all persons hired will be required to verify identity and eligibility to work in United States and to complete the required employment eligibility verfication document form upon hire. * Please select the option 5) I authorize HealthCare Pros to obtain consumer investigation reports from consumer reporting agencies for use in decidingg whether or not to offer me employment. I understand that such reports may include information concerning my credit worthness, credit standing, credit capacity, character general reputation, personal characteristics or mode of living. I understand that if I am denied employment based upon information contained in any credit report, I will be provided with the name, address, and telephone number of the consumer reporting agency, a copy of the report and an explanation of my rights concering it. * Please select the option 6) I understant that HealthCare Pros is committed to maintaining a drug and alcohol free work plan. Accordingly I may be subject to a pre-employment blood test. Urinalysis or other drug/alcohol screening I further understant that if employed, I may be subject to such a drugh and alcohol screening. I HealthCare Pros has reasonable suspiction to believe that I am under the the influence of a drug/alcohol. My consent to submit to such a test is required as a condition of employment and my refusal to consent shell result in a refusal to hire or if already employed termination. * Please select the option 7) I have placed my signature in the space provided below only after I have completed the entire form to the best of my ability and have carefully read and foregoing (7) statements. * Please select the option Social security number * Social Security Number is required Date of Birth * Date of Birth is required Employee Signature * The Client Signature is required Date * The Date is required Back Submit Thank you for submitting your paperwork! Once we receive it we will contact you as soon as possible. Waiting... redirecting shortly. Do not close your browser