Employment Application - Angel Healthcare Staffing

Personal Information
Name*

First NameMiddle InitialLast Name
Current Address*

Street Address

Street Address Line 2

CityState

Zip Code
Have you moved in the past 6 months?

YesNo
Previous Address

Street Address

Street Address Line 2

CityState

Zip Code
Email*
example@example.com
Mobile Phone Number*
Please enter a valid phone number.
Preferred Method of Contact for Application Process

EmailText Message

Candidate Description
In a few sentences, please describe yourself as a candidate for the position you are seeking:

Emergency Contact Information
Name:
Relationship:
Phone Number
Please enter a valid phone number.

Education History

*Please list highest earned educational degree
University:
Location:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Degree
Graduation Year

Licensure

Please include copy of license with your application submission.
License Type
Please list license type:
In what state is this license issued?
Would you like to list an additional License?

YesNo
License Type
In what state is this license issued?
Would you like to list an additional License?

YesNo
License Type
In what state is this license issued?
Would you like to list an additional License?

YesNo
License Type
In what state is this license issued?
Upload License

Cancelof

Qualification/ Skills List

Please list any technical and or business qualifications/ skills you possess:

	Technical Qualifications/Skills List:	Business Qualifications/Skills List:
1
2
3
4

Professional References
Professional Reference #1
Employer Company Name:*
Reference 1
Employment Start Date*

MonthDayYear
Date
Employment End Date*

MonthDayYear
Date
Reference Name:*
Reference 1
Reference Email
example@example.com
Reference Phone
Please enter a valid phone number.
Professional Reference #2
Employer Company Name:
Reference 2
Employment Start Date

MonthDayYear
Date
Employment End Date

MonthDayYear
Date
Reference Name:
Reference 2
Reference Email
example@example.com
Reference Phone
Please enter a valid phone number.
Consent for Reference Check: I understand in order to complete the application process with Angel Healthcare, I must authorize release of information regarding previous or current employment.
Authorization of release:*

Clear

Employment History

Please begin with most current
Employment History #1
Company*
Location*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Job Title*
Employment Start Date*

MonthDayYear
Date
Employment End Date*

MonthDayYear
Date
Description of Achievements and Duties:*
Employment History #2
Company
Location

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Jon Title
Employment Start Date

MonthDayYear
Date
Employment End Date

MonthDayYear
Date
Description of Achievements and Duties:
Employment History #3
Company
Location

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Job Title
Employment Start Date

MonthDayYear
Date
Employment End Date

MonthDayYear
Date
Description of Achievements and Duties:

Statement of Truth
I understand that this document titled “Employment Application” is a legal professional document and all statements made on it must be true and accurate without omission. Falsifying any statements on this document is an offense that is reportable to the appropriate state board. I certify that I am, to be best of my knowledge, in good physical and mental health and able to carry out the duties of the position for which I am applying and that I can carry out these duties without endangering myself or those for whom I provide professional healthcare services.

I authorize Staff Station, dba Angel Healthcare Staffing to investigate my previous employment history, criminal background, and to contact the references listed on this application.

I certify that all statements made on this document are truthful and without intent to misrepresent my abilities to perform my job as a healthcare professional.

I agree to submit to alcohol and/or drug screening tests, if requested of me, at any time prior to or during my employment in accordance with applicable law and I further understand and consent to the results of said tests being communicated to the Company.
Signature*

Clear
Date*

MonthDayYear
Date

Criminal Background Check Authorization
As a prospective employee of Angel Healthcare Staffing, I understand that it is Company Policy to secure criminal conviction information as part of the pre-employment screening process. Nothing contained in this form shall be deemed to constitute a request for consent to obtain any records of information regarding an arrest, detention or disposition of a violation of law in which a conviction does not result, except as to information relative to a pending felony charge.

If any information that is obtained is believed to be inaccurate by applicant it is his/her right to challenge the results within two days of receiving the results. It is the responsibility of the applicant to notify Angel Healthcare Staffing representatives of the intent to challenge.

I have been provided a summary of my rights under the Fair Credit Reporting Act and I authorize Angel Healthcare Staffing or their designated investigation agency to utilize the information listed below for the sole purpose of obtaining a criminal conviction file research.
Applicant Signature*

Clear
Date*

MonthDayYear
Date
Have you ever been known by or used any other name?*

YesNo
If yes, please list:
Date of Birth*

MonthDayYear
Date
Sex

MaleFemale
Social Security Number:*

Agreement to Confidentiality/At Will Employment/ Release of Records
We at Angel Healthcare want to ensure our employees that we respect your status of employment and your professional credentials to be confidential, but also want our employees to be aware that in order to remain compliant with our clients we will have to release information such as; your professional licensures, all professional certifications, dates of health screenings, dates and scores of required testing, and completion dates of required drug screening and criminal background checks.

Please read these following statements, your signature provides written consent to these statements:

❖ I understand that my employment with Angel Healthcare is “at will”, meaning that either myself or Angel holds the right to terminate my employment at any time for any reason without cause. I also understand that neither the interview process nor the orientation process creates an employment contract.

❖ I certify that all statements given on my original Angel Healthcare application and orientation paperwork are true and complete to the best of my knowledge. This being said, I also understand that if any statements are found to be false at any
time of my employment I will be terminated immediately.

❖ I understand that if offered a position with Angel Healthcare I am required to take a drug test that will indicate if I have any drugs in my body that would inhibit me from fulfilling my job duties. If the presence of any substance is detected in the drug screening, there is a possibility of rejection of my application and/or the termination of my employment. I do consent to the drug screening, and understand that the results will be kept in confidence between the employees at Angel Healthcare, and any vendors handling/reading the results. I release any legal liability against Angel Healthcare, its personnel, companies or corporations associated with the distribution of these results due to either a positive screen or refusal to do the screen.

❖ I agree to keep confidential any and all information that is not publicly known about Angel Healthcare and/or about the client’s serviced. Confidential information includes, but is not limited to: financial information, client employee information, client operations, computer records, and patient information.

❖ I acknowledge that is my responsibility to return any and all equipment to the rightful owner after completion of an assignment.
Applicant Signature*

Clear
Date*

MonthDayYear
Date

	YES	NO	If yes, please list expiration date
BLS/CPR
ACLS
PALS
CCRN
CEN
CNOR
NPR

Personal Information

Candidate Description

Position Information

Emergency Contact Information

Education History

Licensure

Certifications

Qualification/ Skills List

Professional References

Professional Reference #1

Professional Reference #2

Employment History

Employment History #1

Employment History #2

Employment History #3

Statement of Truth

Criminal Background Check Authorization

Agreement to Confidentiality/At Will Employment/ Release of Records

Voluntary Equal Employment Identification Form