Application for Employment
You may email your resume or complete the following application.
Please complete all fields of this application.
Please indicate your status:
ShiftAMPM
Date Available for Work
Full Name
Address
City
State
Zip Code
Phone
Cellular Phone
Fax
Page
E-Mail
Emergency Contact:
(not living with you)
Phone
Social Security #
*optional, not secure
US CitizenYesNo
Referred By

EDUCATION

Please list school(s) attended, name and location of school(s), year(s) graducated and type of degree(s).
Nursing/Technical:
University or others:

CERTIFICATIONS & SPECIALIZATION

Professional License or technical certificate
(1)
State: Exp. Date:
(2)
State: Exp. Date:
(3)
State: Exp. Date:
Has your license or certification ever been under investigation? YesNo
If YES, please explain:
CPR/BCLS Expiration Date
NALS/PALS Expiration Date
ACLS Expiration Date

NURSING APPLICATIONS ONLY


If you are a nursing applicant, please complete this next section. Specialty you have performed proficiently in the last two years:
(1)
Years of Experience:
(2)
Years of Experience:
(3)
Years of Experience:
Critical Care Course
(date and place)
Special/National Certifications (e.g., Chemotherapy, CCRN, EKG, Telemetry, IABP, Hi Risk L&D, Cath. Lab, etc.)

ADDITIONAL INFORMATION

Have you ever been convicted of a crime which would bear upon or prohibit your employment at a hospital? Yes No
Have you ever been convicted of a felony? Yes No
Have you ever been a party to a professional malpractice lawsuit? Yes No
If you answered YES to any of the above questions, please explain:
Are you currently employeed? YesNo
If yes, may we contact your employer? Yes No

LIST 3 PROFESSIONAL REFERENCES


Name
Address
Phone
Relationship
Name
Address
Phone
Relationship
Name
Address
Phone
Relationship

EMPLOYMENT EXPERIENCE

Facility
Address
City
State
Zip Code
Immediate Supervisor
Phone
Employment Dates — From: To:
Position Field
Specialty/Unit
Types of Patients
Reason for leaving
Facility
Address
City
State
Zip Code
Immediate Supervisor
Phone
Employment Dates — From: To:
Position Field
Specialty/Unit
Types of Patients
Reason for leaving
Facility
Address
City
State
Zip Code
Immediate Supervisor
Phone
Employment Dates — From: To:
Position Field
Specialty/Unit
Types of Patients
Reason for leaving

Please check the appropriate box for each question. If you answer "YES" to any of the following, please use the box provided to describe details.

A) To your knowledge, are you presently the subject of any investigation or procedure by any agency, registry, or healthcare provider? Yes No

B) Are you now, or have you ever been a defendant in any litigation alleging neglect or impropriety relating to your performance in the field of healthcare? Yes No

C) Has any agency, registry, or healthcare facility within the last five (5) years, cancelled any contract with you as a healthcare professional for any reason other than at your request? Yes No

D) Have you ever been convicted if a crime in the past ten (10) years other than a traffic violation? Yes No

E) During the past ten (10) years, has any license of certification of yours been cancelled, revoked or refused issue or renewal? Yes No

I understand that, if any of the above licensing questions are answered yes, that ADARA Healthcare Staffing, Inc. has the right to deny this application.

I hereby certify that my answers appearing on this application are true. I understand that if any material information given in this application is found to be incorrect or incomplete, it may be grounds for immediate termination at the sole discretion of ADARA Healthcare Staffing, Inc. I give ADARA Healthcare Staffing, Inc. the right to contact my previous employers for verification purposes.

I authorize ADARA Healthcare Staffing, Inc., to release any medical information required for employment to their client facilities. I understand that this information is scanned and posted on a secured web site that is accessible to their client facilities and other affiliates of ADARA Healthcare Staffing, Inc.

I understand that this application is not a contract of employment. I also understand and agree that, if hired, my employment would not be for a definite period and could be, regardless of the date of payment of my wages and salary, terminated at any time without any prior notice, with or without any reason.

ADARA Healthcare Staffing Services, Inc. considers all candidates without regard to race, color, religion, creed, gender, national origin, or any other legally protected status.

I certify that the above answers herein are true and correct to the best of my knowledge.
Yes No

PLEASE READ CAREFULLY

I hereby authorize you to make any investigation of my personal history, criminal history, through any investigative, agencies or bureaus of your choice. I acknowledge that I have been given and read a stand alone, Consumer Disclosure that a consumer report or investigative consumer report may be requested and used for purposes of evaluating me for assignment to facilities.
Yes No
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© ADARA Healthcare Staffing, Inc. All Rights Reserved.
241 Maple Hollow Rd, Duncansville, PA 16635   1.800.936.0072 or 814.693.1415   Fax 814.693.9880
Email: healthcarestaf@gmail.com