Application - Prestigious Nursing - A Nurse Staffing Agency

Personal Information

Application Date(Required)

Your Name(Required)

First Last

Your Email Address(Required)

Enter Email Confirm Email

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How long at present address?(Required)

Phone(Required)

Cell Phone Number

Are you 18 years or older?(Required)

Yes

Employment Type(Required)

Full-Time

Part-Time

Contract

Temporary

How did you learn of this opening?(Required)

Emergency Contact Name(Required)

First Last

Emergency Contact Phone Number(Required)

Emergency Contact Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Education

Name(Required)

High School

Address(Required)

High School

City State / Province / Region Country

Did you graduate?(Required)

Yes

Name(Required)

College

Address(Required)

College

City State / Province / Region Country

Did you graduate?(Required)

Yes

Previous Employment

Please list your previous employers, the dates you worked and the position you held

Former/Current Employer(Required)

Employer

Dates

Position

Phone

Former/Current Employer(Required)

Employer

Dates

Position

Phone

Former/Current Employer

Employer

Dates

Position

Phone

Former/Current Employer

Employer

Dates

Position

Phone

Background Check

A record of criminal or guilty/no contest plea may disqualify an applicant from employment. Relevant factors for consideration may include the following: state laws barring employment in a healthcare facility, date of offense, and nature of the position sought. Declining or failing to fully disclose all convictions and guilty/no contest pleas on this application will result in rejection of the application or termination of employment.

Have you ever been convicted of or pled guilty/no contest to any criminal offense (minor traffic violations excluded)?(Required)

Yes

Level of Offense(Required)

Ex. Misdemeanor, Felony, etc.

Offense Description(Required)

Location of Offense(Required)

City State / Province / Region

Date of Offense(Required)

Have you ever been discharged from or asked to leave employment?(Required)

Yes

If yes, provide details:(Required)

Previous Addresses(Required)

Please list all addresses for the past 5 years.

Home Address

Dates

Previous Addresses

Home Address

Dates

Previous Addresses

Home Address

Dates

Previous Addresses

Home Address

Dates

Professional References(Required)

Include two professional references not related to you, who have known you for at least a year.

Name

Phone Number

Professional References(Required)

Name

Phone Number

Certification of Eligibility to Participate in Federal Health Care Programs

The Office of Inspector General (OIG) may impose financial penalties against health care providers that employ or enter into contracts with excluded individuals or entities to provide items or services to federal program beneficiaries (section 1128A(a)(6) of the Act; 42 CFR 1003.102(a)(2)). Providers such as hospitals, nursing homes and hospices may face\ exposure if they submit claims to a federal health care program for health care items or services provided, directly or indirectly, by excluded individuals or entities. Individuals may be excluded from participation in federal health care programs for a number of reasons including a Medicare/Medicaid fraud or abuse conviction, license revocation, or failure to repay a federal student loan. If a health care provider arranges or contracts (by employment or otherwise) with an individual or entity who is excluded by the OIG from program participation for the provision of items or services reimbursable under such a federal program, the provider may be subject to fines of up to $10,000 for each item or service furnished by the excluded individual or entity, as well as an assessment of up to three times the amount claimed and program exclusion may be imposed. Furthermore, if an excluded individual seeks employment with a Medicare/Medicaid participating provider, it could affect their opportunity for reinstatement at the conclusion of the exclusion period. I certify that I am not subject to exclusion or debarment under federal law or designated in a nurse aid registry as having a finding concerning abuse, neglect, or mistreatment of a patient or misappropriation of a patient’s property.

Electronic Signature(Required)

By typing my name below, I certify that I am the applicant completing this form and that this electronic signature is legally binding and equivalent to my handwritten signature. I affirm that all information provided is true and complete to the best of my knowledge.

Date(Required)

Employment Understanding

It is the policy of the company and all of its subsidiaries to provide equal employment opportunities to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability, or veteran status. I understand that any offer of employment, or continued employment, is contingent upon the company’s decision that the results of my background investigation and/or drug test and other references (work related, personal, license verification (including Nursys) are satisfactory. If employed, 1 will be required to complete an Employment Verification Form (1-9), and within three days show satisfactory evidence of identity and eligibility for employment. I understand that emergency conditions may require me to temporarily work shifts other than the one for which I am applying and agree to such scheduling change as directed by my department head or administrator of this institution. I understand that my employment Is at-will, and that either party Is free to terminate the employment relationship at any time without cause. 1 also understand that my employment may be terminated for any misstatement or omission of fact appearing on this application form.

Electronic Signature(Required)

Date(Required)