Date

    Your Firstname

    Your Middlename

    Your Lastname

    Your Email

    Gender

    Your Home Phone (xxx-xxx-xxxx)

    Your Cell Phone (xxx-xxx-xxxx)

    Driver License Number and State

    Expiration date

    Address, City, State and Zip code

    Date of Birth (fill at office)

    SSN Number (fill at office)

    Can you legally work in the United States?

    Emergency Contact (Name, and Lastname):

    Emergency Contact Phone number (xxx-xxx-xxxx)

    When are you available to start?

    Do you have reliable transportation?

    What is your current availability?

    Number of hours available per week

    Are you available for short notice work?

    Have you ever been employed by MedPro USA Health Services in the past?

    If you have employed by MedPro USA Health Services, when?

    Have you ever been convicted of a felony or misdemeanor offense, including DWI, or participated in a pre-trial deferral or diversion program?

    Have you ever been excluded, debarred, or sanctioned from a federally funded health care program including Medicare, Medicaid, champus, etc?

    Has your professional license ever been suspended, revoked or admonished?

    Have you ever been involuntarily terminated from a job?

    Are there any employers you do not want us to contact?

    Is your professional license under review by the Nursing Board or State you are licensed in?

    If your professional license under review, please explain (will not necessarily exclude you from employment):

    EMPLOYMENT HISTORY (PROVIDE 3 EMPLOYMENT HISTORY)
    Please ensure the address and business name are correct.

    Please start with the most recent employer.

    1. Company Name

    1. Position

    1. Company Address

    1. Company Telephone Number (xxx-xxx-xxxx):

    1. Company FAX Number (xxx-xxx-xxxx):

    1. Are you currently Employed by this Employer

    1. Supervisor's Name:

    1. Supervisor's Phone Number (xxx-xxx-xxxx):

    1. Reason for leaving

    1. Date Start of Employment: START:

    1. End Date of Employment: END:

    1. Starting Salary:

    1. Ending Salary:

    2. Company Name

    2. Position

    2. Company Address

    2. Company Telephone Number (xxx-xxx-xxxx):

    2. Company FAX Number (xxx-xxx-xxxx):

    2. Are you currently Employed by this Employer

    2. Supervisor's Name:

    2. Supervisor's Phone Number (xxx-xxx-xxxx):

    2. Reason for leaving

    2. Date Start of Employment: START:

    2. End Date of Employment: END:

    2. Starting Salary:

    2. Ending Salary:

    3. Company Name

    3. Position

    3. Company Address

    3. Company Telephone Number (xxx-xxx-xxxx):

    3. Company FAX Number (xxx-xxx-xxxx):

    3. Are you currently Employed by this Employer

    3. Supervisor's Name:

    3. Supervisor's Phone Number (xxx-xxx-xxxx):

    3. Reason for leaving

    3. Date Start of Employment: START:

    3. End Date of Employment: END:

    3. Starting Salary:

    3. Ending Salary:

    Can MedPro USA Health Services e-mail your Verification of Employment as attachment


    PROFESSIONAL REFERENCE
    One of your references must be your current/former supervisor.
    Please do not include your friends or relatives. Include only those familiar with your work ability.
    Please contact all of your references that we will call.

    1. Name of your reference:

    1. Reference's phone number (xxx-xxx-xxxx):

    1. Relationship:

    1. Year Know:

    2. Name of your reference:

    2. Reference's phone number (xxx-xxx-xxxx):

    2. Relationship:

    2. Year Know:

    3. Name of your reference:

    3. Reference's phone number (xxx-xxx-xxxx):

    3. Relationship:

    3. Year Know:

    Do you have any work restrictions that we should be aware of?

    If you have work restriction, what is the restriction?

    Can MedPro USA Health Services e-mail your REFERENCE FORM as attachment

    EDUCATION

    HIGH SCHOOL:

    Name of School:

    City/State:

    Graduated? / Degree

    COLLEGE:

    Name of School:

    City/State:

    Graduated? / Degree

    EMPLOYMENT APPLICATION

    Please read carefully

    Was your last name different from your present name during the above listed jobs?

    Have you ever been convicted of a crime in the past 5 years, barring employment in a Home Care and community support Agency?

    Conviction will not necessarily disqualify an applicant from employment.
    If you have ever been convicted of a crime in the past 5 years, describe in full:

    Are you capable of performing the job set forth in the job description?

    If you are not capable of performing the job set, describe in full:

    APPLICANT NOTE

    Please read carefully

    I certify that the facts contained in this application are true and complete to the best of my knowledge and understand,
    that, if employed, falsified statements on this application SHALL BE GROUNDS FOR DISMISSAL.

    I Authorize complete investigation of all statements contained herein and herby give my full permission for the Agency
    to contact and fully discuss my background and history with all persons and entities listed above to give the Agency
    any and all information concerning my previous employment and any information they may have, and release all former employees and others listed above from all liability for any damage that my result from furnishing the same to the Agency.

    This Agency performs random drug screening and prohibits the use of illegal drugs. I understand that I will be subject
    to random drug screening and failure to submit or pass drug screening may result in dismissal for cause. By signing this application, I agree to submit to random drug screening as requested.

    I understand and agree that, if hired, my employment is for no definite period arid may, regardless of the date of
    payment of my wages and salary, be terminated at any time for any lawful reason, without prior notice and with or
    without cause.

    This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant
    wishing to be considered for employment beyond this time period shall inquire as to whether or not applications are
    being accepted at that time.

    MedPro USA Health Services HR will prefill your information to W4, i9, Employment Reference Form, and Employment Verification Form. Do you agree?


    EXPERIENCES

    Do you have TRACH Experience?

    Do you have VENT Experience?

    Do you have G-Button Experience?

    Are you IV Certified?

    CPR?

    Your CPR's Expiration Date:

    Professional License


    Type Of License

    License Number

    State

    Expiration Date

    This application form is intended for use in evaluating your qualifications for employment. This is not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview and on this form are grounds for terminating the
    application process or, if discovered after employment, termination of employment. We are an equal opportunity employer. All qualified applicants will receive consideration without discrimination because of sex, marital status, race, age, creed, national origin or the presence of disabilities.


    CERTIFICATION AND RELEASE

    I, (Please fill your name) , certify that I have read and understand the “Applicant Note” above, and that the answers given by me are complete and true to the best of my knowledge and belief. I understand that any false information or any misrepresentation or omission of facts may result in rejection of my application or discharge at any time during my employment.

    I understand Professional Case Management may conduct an investigation which is not limited to but may include my credit record; criminal record, driving record and workers compensation record, and I consent to such an investigation. Upon request I provide proof of meeting minimum age requirements of applicable laws and submitting proof of true age after hired and proof of citizenship of U.S. and/or proof of employability for the Immigration and Naturalization Service (e.g. passport, driver’s license, I.D. card and/ or Social Security Card.)

    I authorize the company and I or its agents, including consumer-reporting bureaus, to make inquiries and receive information on any or all statements contained in this application. I also authorize any person, school, current employer (except as previously noted), and past employers listed on this application to provide relevant information and opinions that may be useful in making a hiring decision. l release such persons and organizations from any legal liability for any damage whatsoever for issuing this information.

    Applicant Firstname and Lastname

    Date