Application Click headers to open/close each section. If no, please fill out the application below. If you are human, leave this field blank. Applicant Information* Please Note: You must complete this application in full. You will not be able to save a draft. Date of Application * Last Name * First Name * Middle Initial * Please list any other names you have worked under Street Address * Address Line 2 City * State * Zip Code * Email Address * Phone Number * Date Available * Social Security Number * Desired Salary * Position Applied For To select multiple positions, hold the Shift key and use your mouse to select. Or leave this field blank to submit a general application. Are you a citizen of the United States? * Yes No If no, are you authorized to work in the US? * Yes No Have you ever worked for this company? * Yes No If so, when? * Have you ever been convicted of a felony? * Yes No If yes, explain. * Discipline * BHT CMA CNA CRT LCSW LPN NP OT PA Physician Psychiatrist Psychologist PT PTA RN RRT Other Discipline Speciality (Please type N/A if no specific Speciality) * Years of Experience * Less than 1 year 1-5 years 5+ years Certifications (we require American Heart Association) * N/A ACLS BLS PALS To select multiple certifications, hold the Shift key and use your mouse to select. Discipline Certification/License Number * DEA Number, if applicable National Provider Identifier (NPI) Number, if applicable Have you been involved or named in any malpractice suits? * Yes No If yes, please provide a brief description including any settlement amounts on your behalf. Have you had any restrictions with Medicare or Medicaid? * Yes No If yes, please explain. Have you had any addictions to any controlled substances that would affect your ability to perform the duties assigned? * Yes No If yes, please explain. Have you had any disciplinary actions with any licensing board? Issues obtaining privileges at any facilities? Any restrictions or issues with your DEA? * Yes No If yes, please explain.
