Employment Application - Holsman Healthcare

General Information

First Name *

Middle Name

Last Name *

Maiden Name

Address *

City *

State *

Zip Code *

Home Phone

Cell Phone *

Other Contact Number

Email Address *

Best Time to Contact

How did you hear of Holsman Healthcare?

Emergency Contact

Name *

Relationship *

Phone Number *

Address

Employment Profile

Do you have any limitations that would restrict you from performing essential functions? Yes No

Are your driving privileges suspended or revoked in any state? Yes No

Can you provide proof of auto insurance for rental car usage? Yes No

Are you willing to submit to a criminal background check? Yes No

Are you willing to submit to a drug screen? Yes No

Can you provide proof of eligibility to work in the United States? Yes No

Have you ever been convicted of a crime that would prevent employment at a health care facility? Yes No

Have you ever had a license or certification investigated, revoked, or suspended? Yes No

Do you have at least one year of current experience on a hospital floor? Yes No

Education

School / University *

Location

Month / Year Graduated

Degree / Diploma Awarded *

Expertise / Experience

Specialty *

Years of Experience *

Equipment / Procedures

Work History

List below all permanent positions (full-time & part-time), local agency, and travel assignments.

Position 1

Facility

Location

Dates Employed

Position Type

Full-time Part-Time Local Agency Travel

Supervisor

Phone

Salary

Reason for Leaving

Position 2

Facility

Location

Dates Employed

Position Type

Full-time Part-Time Local Agency Travel

Supervisor

Phone

Salary

Reason for Leaving

Position 3

Facility

Location

Dates Employed

Position Type

Full-time Part-Time Local Agency Travel

Supervisor

Phone

Salary

Reason for Leaving

Professional References

Reference 1

Name

Title

Facility

Contact Number

Reference 2

Name

Title

Facility

Contact Number

Reference 3

Name

Title

Facility

Contact Number

Licensure

State *

License Number *

Issue Date

Expiration Date *

State

License Number

Issue Date

Expiration Date

Certifications

Other Certifications

Application Certification

I certify that all statements made in this application are true to the best of my knowledge. I understand that any falsification or misleading information given in my application may result in the termination of my employment with Holsman Healthcare, LLC.

Furthermore, I understand that my professional conduct and clinical performance is directly related to my ability to be placed on assignments for Holsman Healthcare and that I will adhere to all expectations set forth in the employee handbook.

I authorize Holsman Healthcare, LLC to verify the information I have provided, to contact references, and to conduct a criminal background check concerning my ability, character, and past employment record.

I understand that nothing contained in this application is intended to create an employment contract, either verbal or written, with Holsman Healthcare, LLC or its clients. Furthermore, I understand that in the event of my employment, it is "at will" and that Holsman Healthcare or I may terminate my employment at any time with or without notice and with or without cause.

Full Name (Type to Sign) *

Date *