Provider Recruitment Application

Provider Application

Please complete the form below to apply for a position with us.
Full Name*

First NameMiddle NameLast Name
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address*
example@example.com
Phone Number*
Format: (000) 000-0000.
Please select the position you are applying for:*
How did you hear about us or this position?*
If other, please state how you heard about this position.
Available Start Date*

MonthDayYear
Date
YesNo
From:
To:
Department:
Position Held:

Licensing
License Type*
License Number*
License State*
License Expiration Date*

MonthDayYear
Date
YesNo

License Type
License Number
License State
License Expiration Date

MonthDayYear
Date
YesNo

License Type
License Number
License State
License Expiration Date

MonthDayYear
Date

Previous Employment
Company*
Phone:*
Employment Dates (From - To)*
Title*
Duties*
Starting Salary*
Ending Salary*
Supervisor's Name*
Supervisor's Title*
Reason for Leaving*
Resume

Please upload a copy of your resume.
Upload Your Resume*

Cancelof

Additional Information
YesNo
If no, please explain.
YesNo
YesNo
If yes, briefly describe the nature of the crime(s), the date and place of convictions(s), and the legal disposition of the case(s).

Attestation
I certify that all information provided in this employment applicationis true and complete. I understand that any false information or omission maydisqualify me from further consideration for employment and may result in my dismissalif discovered at a later date.I authorize the investigation of any or all statements contained in thisapplication. I also authorize, whether listed or not, any person, school,current employer, past employers and organizations to provide relevantinformation and opinions that may be useful in making a hiring decision. Irelease such persons and organizations from any legal liability in making suchstatements.I understand I may be required to successfully pass a drug screening examination. I hereby consent to a pre- and/or post-employment drug screen as a condition of employment, if required.I understand that if I am extended an offer of employment it may be conditioned upon my successfully passing a complete pre-employment physical examination. I consent to the release of any or all medical information as may be deemed necessary to judge my capability to do the work for which I am applying.I UNDERSTAND THAT THIS APPLICATION, VERBAL STATEMENTS BY MANAGEMENT, OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE AN EXPRESS OR IMPLIED CONTRACT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. ONLY THE CHIEF EXECUTIVE OFFICER (CEO) OF THE ORGANIZATION HAS THE AUTHORITY TO ENTER INTO AN AGREEMENT OF EMPLOYMENT FOR ANY SPECIFIED PERIOD AND SUCH AGREEMENT MUST BE IN WRITING, SIGNED BY THE CEO AND THE EMPLOYEE. IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME, WITH OR WITHOUT REASON AND WITH OR WITHOUT NOTICE.
I have read, understand, and by my typed name below consent to these statements above.*

First NameLast Name
Authorization for Background Investigation
In connection with my employment, I understand that the Company will conduct a background investigation on me. The investigation will involve obtaining a consumer report (as defined by federal law) involving matters regarding my character, general reputation, personal characteristics, and mode of living. Specifically, the Company will confirm the following: identity, employment, education, driving record, OIG, criminal record and general public records history. I further understand the Company may, during the course of my employment, conduct a similar background investigation to determine my suitability for promotion, reassignment or retention.

By initialing below, you agree to the following:

1. I have read and understood the Authorization for Background Services.

2. I understand that we will perform a background check on me during the interview process.

3. I understand that by initializing this form, I am not authorizing the background check.

4. I understand that by initializing this form, I am not declining the background check. I understand that my signature will be required in order to authorize the background check and that my signature may be obtained at a later date.
Please type your initials here to consent to the above. *
Should be Empty:

Provider Application

Licensing

Previous Employment

Resume

Additional Information

Attestation

Authorization for Background Investigation