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Employment Application

Required fields are indicated by " ● "

● First Name: 

 

Middle Name:

 

● Last Name:

 

● Social Security #:

 

● Street Address/P. O. Box:

 

● City:

 

● State:

 

● Zip:

 

● Home Phone:

 

Cell Phone:

 

Fax:

 

Pager:

 

● E-mail Address:

 

Emergency Contact Name:

 

Emergency Contact Phone:

 

Driver's License State:

 

● Are you legally authorized to work in the United States?

Yes     No

● Have you ever been convicted of any misdemeanor or felony within the last 7 years?

Yes     No

Check as Appropriate:

(Certification)

RN     LPN      CNA

Employment Position Desired:

 

● Type of Employment Desired:

Per Diem     Full Time

Type of Shifts:

8 Hour Shifts
12 Hour Shifts
10 Hour Shifts
16 Hour Double Shifts
Other
Shift Preference:

Day
PM
Night

Professional Licensure/Certification

 
State:

 

License Number:

 

Expiration Date:

   (mm/dd/yyyy)
 

Expiration Date
CPR/BLS

  (mm/dd/yyyy)
ACLS

  (mm/dd/yyyy)
NALS/NRP

  (mm/dd/yyyy)
PALS

  (mm/dd/yyyy)
IV CERT

  (mm/dd/yyyy)
CCRN

  (mm/dd/yyyy)
TNCC

  (mm/dd/yyyy)
Employment History
Clinical positions most recent first
  
1.  
Employed from:

 (mm/dd/yyyy)
Employed to:

 (mm/dd/yyyy)
Facility:

 

Street Address:

 

City:

 

State:

 

Zip:

 

Facility Supervisor's Name:

 

Facility Supervisor's Title:

 

Facility Supervisor's Phone Number:

 

Your Position:

 

2.  
Employed from:

 (mm/dd/yyyy)
Employed to:

 (mm/dd/yyyy)
Facility:

 

Street Address:

 

City:

 

State:

 

Zip:

 

Facility Supervisor's Name:

 

Facility Supervisor's Title:

 

Facility Supervisor's Phone Number:

 

Your Position:

 

3.  
Employed from:

 (mm/dd/yyyy)
Employed to:

 (mm/dd/yyyy)
Facility:

 

Street Address:

 

City:

 

State:

 

Zip:

 

Facility Supervisor's Name:

 

Facility Supervisor's Title:

 

Facility Supervisor's Phone Number:

 

Your Position:

 

 

Please Read Carefully Before Accepting

My signature below verifies that the information I have given on the application and resume (if included) is correct and complete. Any misrepresentation or omission may result in my dismissal. I authorize the company (HSI) and its authorized representatives to contact and obtain information from schools, persons and past and present employers in connection with my application for employment. I agree to cooperate with such reference checks and release from liability all persons and corporations requesting and providing such information.

I understand that, if hired, my employment will continue for an indefinite period and may be terminated by me or the employer at any time with or without cause. HSI cannot guarantee the days, hours, or shifts that an employee works, and may be required to work varying times and hours.

I accept     I decline


Equal Employment Opportunity

The Company is committed to a policy of equal opportunity to all qualified persons without regard to age, race, creed, color, national origin, sex, marital status, religion, physical or mental handicap (if unrelated to the performance of essential functions of the job after reasonable accommodation is provided), or veteran status. It is our intent and desire that equal employment opportunity will be provided in all activities related to recruiting, hiring, transfers, promotions, compensation, benefits, training, Company-sponsored social and recreational programs, and all other privileges, terms and conditions of employment.


Harassment Free Environment

The Company is committed to providing a work environment that is free of sexual, racial, ethnic or religious harassment. Such behavior undermines the integrity of the employment relationship and is inconsistent with the philosophy of the Company and with sound management practice. This policy prohibits harassment in any form, including verbal, physical and visual. No sexual, racial or ethnic slurs will be tolerated.

Any incident of discrimination or harassment should be reported immediately to the Human Resource Manager. If you cannot do that, notification should be made to the President. In all cases, reasonable measures will be taken to protect the complaining employee from any retaliatory harassment or abusive behavior by other employees, by patients, vendors or suppliers.

All complaints will be investigated promptly. Employee conduct which results in discrimination or harassment against other employees, patients, vendors or suppliers is illegal and will result in corrective disciplinary action, including possible discharge.