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

	1 2 3 4
{{skill_key}}

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

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Has your License/Certification ever been revoked or suspended?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

Just a few more questions

1) Are you at least 18 years or older? *

Please select Yes or No

Yes

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

5) If hired, can you present evidence of your eligibility to work in United States? *

Please select Yes or No

Yes

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

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

EMPOLYEE APPLICATION

BUILD YOUR PROFILE

How strong are your skills?

How strong are your skills?

{{healthcare.step1.UnitSpeciality }}

{{basicnursing}}

Tell us where you have worked

Important Part

Just a few more questions

Let's wrap this up

Thank you for submitting your paperwork! Once we receive it we will contact you as soon as possible.