Lifespan Medical Personnel

Date Employed

Work Performed

Telephone:

Job Title:

Supervisor:

Hourly Salary

Reason for Leaving

Employment Application
we consider all applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital status or veteran status, or any other legally protected status. I accept that I am applying for a per diem aasingment postion only. Lifespan Medical Personnel can not guarantee hours.
First Name:		Last Name:	Middle Name:
Permanent Address:	Address: City: State: Zip Code:
Previous Adress:	Address City: State: Zip Code:

Telephone:	Email Address:	SSN#:
Valid Driver License:	State:	Expiration Date: exp 10/10/1900

Date of Application:	Date Available to Start:
Position Applied for:	Number of Hours Per Week:
Employement Status Desired?(Please Check all that apply) Shift: Day Evening Night Weekend Rotating Shift
Are you Eligible for Employment within the United States? Yes No Proof or Citizenship or immigration status will be required upon Employment
Are you now or have you ever been sanctioned by or excluded from the Medicare and/or Medicaid system?......... Yes No Have you ever been Bonded? .......................................................................................................................... Yes No If yes what Jobs?..................... Have you ever been employed by us before?................................................................................................................... Yes No If yes, give dates...................... Do any of your friends or relatives work here?................................................................................................................ Yes No If yes, give names and relationship................

	Name and Adress of Schools or University	Major Course of Study	Number of Years Completed	Degree/Diploma
High School
Trade School
Undergraduate College
Graduate Study
Other (Specify)

Certification, Registration or License Type	Document Number	State	Date Issued	Expiration Date	Temporary or Permanent	HR Staff Verified
					T P
					T P
					T P
Has your License/Registration/Certification ever been under review, revoked, or suspended becasue of activity related to patient care or the performance of your duties in your profession?..................................................... Yes No

Starting with your present or most recent job, Include any job-related military service assignments, You may exclude organizations which include race, color, religion, gender, national origin, disabilities or other protected status
Employer:		Date Employed		Work Performed
		From	To
Address:
Telephone:
Job Title:	Supervisor:	Hourly Salary
Reason for Leaving

List Professional, trade, business, or civic activities and offices held.
you may exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability or protected status:

Other Qualifications

Summarize special job-related skills and qualifications or additional information you feel may be helpful to us in considering your application.

Note to applicants: DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING.

Are you capable of performing in a reasonable manner, with or without a reasonable accommodation, the activities involved in the job or occupation for which you have applied? A review of the activities involved in such a job or occupation has been given..................................................................................... Yes No

REFERENCES
Name:	Phone:
Address:	Association	Year Known
Name:	Phone:
Address:	Association	Year Known
Name:	Phone:
Address:	Association	Year Known

How did you learn about our Facility

Advertisement (Please List Publication):
Web Posting(Please list site):
Inquiry:	Date:	Time:
Friend/Rleative:
Other:

Signature indicates that (1) the Company has a drug and alcohol policy that provides for pre-employment testing as well as testing after employment (2) consent to and compliance with such policy is a conditionof my employment, and (3) continued employment is based on the successful passing of the testing under such policy.

I certify that answers given herein are true and complete.

I authorize investigation of all statements contained in the application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, and employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writting by an authorized executive of this organization.

in the event of employment, I understand that false or misleading information given in my applicatonor interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

Full Name

Date:

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