WTS Healthcare Employment Application

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We are now Paperless! Please complete the digital application below to apply for a position with us.
Name*

PrefixFirst NameMiddle NameLast Name
Drivers License #*
State Issued*
What state was your identification issued
Expiration Date*
Social Security Number *
Provide you U.S. 9 digit SS #
Date of Birth*
Ex: 10/08/2005
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Secondary Phone Number*

Area CodePhone Number
Email Address*
example@example.com

Education
Do you have a High school Diploma or GED?*
Education | Name of College or Institution*
School(s) attended, degrees, Certifications Skills and qualifications, Grade Point Average (G.P.A.) Extracurricular activities where you held a leadership role, Honor societies
Institution Location*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
From*

MonthDayYear
Date
To*

MonthDayYear
Date
Degree Earned*
List Specialities
Please list Specialities related to the position in which you've applied

Employment History
Have you been convicted of a misdemeanor, felony including traffic violations within the past 5 years? *
If Yes, Please explain details with recruiter during the phone interview.
Have you ever been discharged from an employer?*
Have you ever worked for an employment agency?
If Yes, Please list the 2 most recent. If No, Leave Blank
Recent Employer*
Employer Name, Supervisor's Name-Your Job Title and Responsibilities, Salary, Reason for leaving.
Employers Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employers Contact

Area CodePhone Number
From*

MonthDayYear
Date
To*

MonthDayYear
Date
Can we contact this employer?*

YesNo
List 2 Professional References*
Name, Job title, Company, Phone, Email

Background Check
I __________________ hereby give WTS Medical Staffing, LLC permission to conduct and investigation to obtain information which WTS Medical Staffing, LLC thinks is necessary to determine my qualifications for employment with the company, including but not limited to, my permission to contact any former employer and personal professional references, banks, credit or financial bureau or office, police department, law enforcement agency, any consumer reporting agency, personal or otherwise, that such sources may have relating to my character,general reputation, or criminal records, and I give my consent to any source to release to WTS Medical Staffing, LLC whatever information they have about me.

I also understand that the information requested about me in the application process is necessary so that the accurate information is obtainable. I hereby consent to this investigation and authorize WTS Medical Staffing, LLC to procure a consumer report on my background as started above from a consumer reporting agency. I also unconditionally release all named and unnamed sources from all liability which might result from furnishing any information about me.

Background Authorization
Name*

First NameLast Name
Signature*

Clear

Confidentiality Agreement
As a condition of my assignment by WTS Medical Staffing, LLC to the client, I hereby agree as follows: I will not use, disclose, or in any way reveal or disseminate to unauthorized parties any information I gain through contact with materials or documents that are made available through my assignment at client or which I learn about during such assignment.
I will not disclose or in any way reveal or disseminate any information pertaining to client or staffing agency or its operating methods and procedures that come to my attention as a result of this assignment.
Under no circumstances will I remove physical or electronic documents or copies of documents from the premises of the client or staffing agency.
I understand that I will be responsible for any direct or consequential damages resulting from any violation of this agreement.
I understand that any breach of confidentiality may be grounds for immediate termination of employment as well as any appropriate legal actions.The obligation of this agreement I hereby understand and accept.
Name*

First NameLast Name
Signature*

Clear

Benefits Waiver
In consideration of my assignment to CLIENT by STAFFING FIRM, I agree that I am solely an employee of STAFFING FIRM for benefits plan purposes and that I am eligible only for such benefits as STAFFING FIRM may offer to me as its employee. I further understand and agree that I am not eligible for or

entitled to participate in or make any claim upon any benefit plan, policy, or practice offered by CLIENT, its parents, affiliates, subsidiaries, or successors to any of their direct employees, regardless of the length of my assignment to CLIENT by STAFFING FIRM and regardless of whether I am held to be a common-law employee of CLIENT for any purpose; and therefore, with full knowledge and understanding, I hereby expressly waive any claim or right that I may have, now or in the future, to such benefits and agree not to make any claim for such benefits.
Name*

First NameLast Name
Liability
I understand that any assignment I accept through WTS Medical Staffing, LLC DBA WTS Health is based on the agreement between WTS Health and its Clients, and the client facilities that I may accept to cover shifts at which they are assigned to me.
Client Facility has the right and privilege to cancel or modify the terms of the assignment with or without notice. I understand and accept that WTS Health will not be liable for any consequential damages, losses, expenses, inconveniences, or loss of alternative employment as a result of the Client Facility’s changes to the assignment. I understand WTS Health will be obligated to pay only for the approved hours worked as indicated on a client‐approved
timesheet.

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.

I authorize the investigation of all statements contained herein and the references listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you.

I understand and agree that, if hired, my employment is provided on an at-will basis for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without prior notice."
Signature*

Clear
Name*

First NameLast Name
Should be Empty:

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Education

Employment History

Additional Information

Background Check

Confidentiality Agreement

Benefits Waiver

Liability