Pride Medical Staffing

APPLICATION IN THE MEDICAL FIELD

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CNA RN LPN/LVN OR TECH RADIOLOGY TECH OTHER ALLIED HEALTH
Travel Perdiem/Local Permanent MISC PRACTITIONER
Name:
Address:
City:
State:
Zip:
Phone:
Mobile:
Date of Birth:
Email Address:
Social Security Number:
Date Available for Employment:
**City of Preference in CA:
Shift Preference: AM PM NIGHT
Area of clinical expertise: Clinical Expertise

Professional Education

Name of School/University:

year Graduated/Degrees:

License Information

State1: License#: Expiration Date:

State2: License#: Expiration Date:

Has your license ever been under investigation?
No Yes
(If yes,please explain)

Has your license ever been suspended, revoked, or provisional in any state? No Yes
(If yes,please explain)

Is your license under current investigation for addiction or clinical competency issues? No Yes
(If yes,please explain)

Most Recent Employment

Hospital:

Address: Phone:

City: State: Zip:

Trauma Facility? Yes No If yes, what level?

Was this a travel assignment? Yes No
If yes, what agency?

Date From: To:
Type of unit:

Reason for leaving:

Reference/Supervisor:

Second Employment

Hospital:

Address: Phone:

City: State: Zip:

Trauma Facility? Yes No
If yes, what level?

Was this a travel assignment? Yes No
If yes, what agency?

Date From: To:
Type of unit:

Reason for leaving:

Reference/Supervisor:

Third Employment

Hospital:

Address: Phone:

City: State: Zip:

Trauma Facility? Yes No
If yes, what level?

Was this a travel assignment? Yes No
If yes, what agency?

Date From: To:
Type of unit:

Reason for leaving:

Reference/Supervisor:

Certifications

ACLS certified: Yes No
Expiration Date:

CPR: Yes No
Expiration Date:

Other Certifications: Yes No
Expiration Date:

Medical History

Current Health Status: Excellent Good Fair Poor

Date of last physical exam: Allergies:

Date of PPD: Date of MMR:

In case of emergency, notify:

Phone: Relationship:

CERTIFICATION AND SIGNATURE

NOTICE OF DRUG TESTING: PRIDE MEDICAL STAFFING, HEREIN REFFERRED TO AS THE "COMPANY" MAY CONDUCT DRUG TESTING OF THE JOB APPLICANTS. SHOULD YOU BE CONSIDERED FOR EMPLOYMENT BY THIS COMPANY, YOU MAY BE CONTACTED REGARDING THE TIME AND LOCATION OF THE PRE-EMPLOYMENT DRUG TEST. REFUSAL TO TAKE THE DRUG TEST OR FAILING THE DRUG TEST WILL DISQUALIFY YOU FROM FURTHER CONSIDERATION FOR A POSITION.
AUTHORIZATION AND UNDERSTANDING: I CERTIFY THAT INFORMATION GIVEN HEREIN IS TRUE AND COMPLETE WITHOUT QUALIFICATION. I UNDERSTAND THE COMPANY MAY INVESTIGATE MY WORK AND PERSONAL HISTORY AND VERIFY ALL DATA GIVEN ON THIS APPLICATION, ON RELATED PAPERS, AND IN INTERVIEWS AND I AUTHORIZE COMPANY, TO DO THE SAME. THIS INQUIRY MAY INCLUDE INFORMATION AS TO MY CHARACTER,GENERAL REPUTATION AND PERSONAL CHARACTERISTICS, AND I CONSENT TO THE CONDUCT OF THIS INQUIRY AND OR THE CONSIDERATION OF ANY STATEMENT OF REFERENCES OF FORMER EMPLOYERS THAT ARE GIVEN IN RESPONSE TO THE INQUIRY.I AUTHORIZE ALL INDIVIDUALS, SCHOOLS AND EMPLOYERS'NAMES THEREIN, EXCEPT AS SPECIFICALLY LIMITED ON THIS APPLICATION, TO PROVIDE INFORMATION REQUESTED ABOUT ME, AND I RELEASE THEM FROM LIABILITY FOR DAMAGES IN PROVIDING THIS INFORMATION. I UNDERSTAND AND ACKNOWLEDGE THAT COMPANY WILL TERMINATE MY EMPLOYMENT IF I HAVE PROVIDED INCOMPLETE, INACCURATE,UNTRUE OR MISLEADING INFORAMATION IN THIS APPLICATION OR ON ANY ORTHER DOCUMENT OR FORM AT ANY TIME DURING MY EMPLOYMENT.
IF TERMINATED, I AUTHORIZE COMPANY TO USE ANY INFORMATION IN ITS POSSESSION CONCERING ME FOR REFERENCE PURPOSES AND/OR IF LEGALLY REQUIRED TO FURNISH ANY INFORMATION INCLUDING DISCLOSURE OF INFORMATION TO A THIRD PARTY, FUTURE EMPLOYER OR PROSPECTIVE EMPLOYER, WITHOUT RECEIVING ANY PRIORY NOTICE, AND I RELEASE COMPANY FROM LIABILITY IN CONNECTION WITH SUCH USE OR DISCLOSURE.
IN CONSIDERATION OF MY EMPLOYMENT I AGREE TO CONFORM TO THE RULES AND REGULATIONS OF COMPANY AND THE DIRECTIONS OF ITS SUPERVISORS, I UNDERSTAND AND ACKNOWLEDGE THAT IF EMPLOYED, UNLESS MY EMPLOYMENT BECOMES SUBJECT TO A COLLECTIVE BARGAINING AGREEMENT, MY EMPLOYMENT AND COMPENSATION WILL BE AT THE WILL OF COMPANY AND CAN BE TERMINATED WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE, AT ANY TIME AT THE OPTION OF EITHER COMPANY OR MYSELF. I FURTHER UNDERSTAND AND AGREE THAT NO MANAGER, REPRESENTIVE, AGENT OR EMPLOYMENT OF COMPANY OTHER THAT THE OWNERS, HAS NOW OR HAS HAD IN THE PAST ANY AUTHORITY TO ENTER INTO ANY AGREEMENT FOR EMPLOYEES FOR ANY SPECIFIED PERIOD OF TIME OR TO MAKE ANY AGREEMENT WHICH IS CONTRARY TO OR A MODIFICATION OF THE ABOVE DESCRIBED EMPLOYMENT RELATIONSHIP, AND THAT ANY SUCH AGREEMENT OR REPRESENTATION MUST BE IN WRITING AND SIGNED BY BOTH MYSELF AND THE OWNERS OF COMPANY IN ORDER TO BE EFFECTIVE.
I FURTHER UNDERSTAND THAT MY EMPLOYMENT IS CONDITIONAL UNTIL SUCH TIME AS THE RESULTS OF ANY PREEMPLOYMENT DRUG TESTING IF ANY IS REUQIRED, ARE KNOWN. I ALSO UNDERSTAND AND ACKNOWLEDGE THAT, AS A PART OF THE HIRING PROCESS AND THROUGHOUT MY EMPLOYMENT, IF HIRED, I MAY BE REQUIRED TO SUBMIT TO MEDICAL/PHYSICAL EXAMINATION AT THE EMPLOYER'S DISCRETION AND EXPENSE.
ALL ORIGINAL DOCUMENTS ARE PROPERTY OF COMPANY.
I CERTIFY THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE AND COMPLETE WHETHER MADE BY ME OR OTHERS AT MY REQUEST. I UNDERSTAND THAT IF HIRED, I MUST PROVE THAT I AM LEGALLY AUTHORIZED TO WORK IN THE UNITED STATES. I AUTHORIZE THE COMPANY TO CHECK EMPLOYMENT REFERENCES AND VERIFY EDUCATION INFORMATION PROVIDED ON THIS EMPLOYMENT APPLICATION AND AS DISCLOSED IN THE INTERVIEW PROCESS. I AUTHORIZE THE COMPANY TO CHECK MY DRIVING RECORD IF THE POSITION FOR WHICH I AM APPLYING REQUIRES DRIVING. YOU MAY BE ASKED TO SUBMIT TO A PRE-EMPLOEMENT DRUG TEST, A CREDIT HISTORY CHECK AND/OR CRIMINAL HISTORY BACKGROUND CHECK AS CONDITION OF EMPLOYMENT. I RELEASE THE COMPANY AND ALL PROVIDERS OF INFORMATION FROM ANY LIABILITY AS A RESULT OF FURNISHING AND RECEIVING ANY INFORMATION RELATED TO THE COMPANY'S HIRING PROCESS.
BY ELECTRONICALLY SUBMITTING MY APPLICATION MATTERIALS, I AGREE TO THE CONDITIONS STATED IN THIS "CERTIFCATION AND SIGNATURE" SECTION IS ENFORCEABLE AS IF I HAD SIGNED BELOW.
SIGNATURE: (Last 4 digits of your SSN) Reenter your last 4 digits of your SSN: DATE: