Expert Care Inc.

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A Preview of the Employment Application

Please complete all questions. Includes any supplemental information which you feel would be helpful in considering your qualifications.

ExpertCare Incorporated is an equal opportunity employer and abides by all applicable federal and state laws prohibiting discrimination in employment because of ethnicity, color, gender, sexual orientation, religion, national orgin, age, handicap, medical condition or martial status

Today's Date:

Source of Referral:

* Required Fields

Personal Information:
*First Name:		*Last Name:
Other Name:		Email:
*Citizen:		DOB:
*Driver license:		*Social Security#:
Current Information:
*Current address:		*Current City:
*Current State:		*Current Zipcode:
*Current Phone:		Celluar Phone:
Pager:		Fax:
Emergency Information:
Contact Name:		Contact address:
Contact City:		Contact State:
Contact zipcode:		*Emergency Phone:

*US Citizen YES NO
If NO, please provide evidence of work
authorization appropriate for the position applied for.

Have you ever gone by another name? Yes: No:
If Yes, Please list below

Education
School Name	School address	Mo/Yr Graduated	Degree(s)

MO/YR. Passed State Board(s):

State:

SUMMARY OF WORK EXPERIENCE/AREAS WORKED

Clinical Area	Years of Exp.	Dates Worked	Clinical Area	Years of Exp.	Dates Worked

BRIEFLY DESCRIBE THE TYPE OF WORK IN WHICH YOU ARE BEST QUALIFIED:

Rn Licensure
State	Number	Expires	State	Number	Expires

Certification
Name	Expires	Name	Expires	Name	Expires

*HAVE YOU EVER BEEN CONVICTED OF A FELONY? YES NO:
IF YES EXPLAIN WHEN, WHERE, TYPE OF OFFENCE AND DISPOSITION OF CASE (A conviction will not necessarily disqualifed applicant from the job applied for)
Have you ever had disciplinary action taken against any of your nursing licences, or are you currently the subject of a report or investigation? Yes: No: If YES give details

REFERENCES

Name four persons in your field who you will be contracting for references, and whom we have permission to contact immediately for preliminary reference information. At least 2 of these persons should be supervisors under whom you have worked

Name	Where Employed	Business Phone	Reference

Explain Breaks

*Date Available

Shift am,

Shift pm,

Shift NOC,

8 Hour,

12 Hour,

Holiday

Clinical Area Preferred:

Have you ever worked as a travel RN

Did you successfully complete your travel assignments?

Note any other details which should be considered in view your qualification. Include affiliations, honors and awards, publications, patient testimonials, etc. (excluding any names of patients).

AUTHENTICITY STATEMENT I hereby certify that the answers given by me to the foregoing questions and statements made are true and correct without consequential omissions of any kind whatsoever, and that I have not knowingly withheld any information regarding my employment together with information they may have regarding me, whether or not it is on their records. I agree that my previous employer shall not be held liable in any respect if any employment offer is not tendered, is withdrawn or my employment is terminated because of false statements, answers or omissions made by me in this questionarie. I hereby release said employers, schools or persons from all liability whatsoever for issuing this information. Also, I understand and agree that my position is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without previous notice.
I understand that falsification of information will be basis for disqualification or termination of employment. CONTENT FOR DRUG/BACKGROUND SCREENING. I understand that drug/background screening is required and I agree to undergo such screening when requested.
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*Signature

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