Suwannee Medical Personnel

Employment Application



Please select a Branch/City where you want your application sent from the drop down selection. You should select the location nearest to where you live or want to work. If you are uncertain of the right location, select Corporate.


     

Your Info
Postion Applied for
 Date
Full Name

Last, Middle, First
Address

Street, City, State, & zip
Phone
 Email
 Social Security Number
Emergency Contact Info
Name
 Phone
 Relationship
Referred by
Licenses and Certifications
License 1

Type ....... State ......... Number ..........Expiration
License 2

Type ....... State ......... Number ..........Expiration
Certification 1

Type ....... State ......... Number ..........Expiration
Certification 2

Type ....... State ......... Number ..........Expiration
Eduction
School 1

Years Attended .............. School Name ................................ Degree Earned ............................... Address
School 2

Years Attended .............. School Name ................................ Degree Earned ............................... Address
Work Experience
Date

Beginning Date .......... Ending Date 		Employer Name and Phone
Supervisor and nature of work responsibilities

Hourly Rate/Salary
Reason for Leaving
Date

Beginning Date .......... Ending Date 		Employer Name and Phone
Supervisor and nature of work responsibilities

Hourly Rate/Salary
Reason for Leaving
Date

Beginning Date .......... Ending Date 		Employer Name and Phone
Supervisor and nature of work responsibilities

Hourly Rate/Salary
Reason for Leaving
Personal References
Reference 1

Name .................. Address .................. Phone
Reference 2

Name .................. Address .................. Phone
Experience/Profile
Please check professional discipline
RN     LPN     CNA     Other         How many years of experience in your professional discipline?
Has your professional license ever been suspended, sanctioned or revoked?
Yes     No
If Yes, Please Explain


Please indicate the number of years experience in each of the following:
Hospital     Nursing Home     Clinic     Corrections     MD Offfice     Industrial

Home Health     Rehab Center     Dialysis Clinic     Consultant     Military     Teaching

List ALL competencies, specialties and areas of expertise and number of years experience, example; NICU 2 years, Oncology 1 year, ER 8 years, etc...
Specialty 1
Years
Specialty 2
Years
Specialty 3
Years
Specialty 4
Years
Specialty 5
Years
Work Preference and Availability
Please check the type(s) of assignments you prefer
Hospital     Nursing Home     Home Health     Clinic     Corrections     MD Office     Other    
Please check the shift(s) you prefer to work
7am-3pm     3pm-11pm     11pm-7am     7am-7pm     7pm-7am    
More General Information
Can you legally work in the United States?

Proof of citizenship or immigrations status will be required upon employment
Do you have personal vehicle liability insurance?
Do you have a current, valid drivers license?
Have you ever been convicted of a crime, plead no contest, or had a judication withheld?
If yes, please explain


I understand that any false answers or statements made to the representative(s) of Suwannee Medial Personnel ("The Company") during the interview process will be sufficient grounds for refusal to hire or immediate discharge regardless of time of discovery.

I understand and agree that Iif I am offered conditional employement with the Company, my hire is for no definite period of time and regardless of the date of payment of my wages or salary., I may be terminated at any time without prior notice or cause and I may be subject to change in wages, conditions, benefits and operating policies. I understand that any employment agreement with the Company must be in writing.

I understand that the Company may make a thorough investigation of my character, reputation, staus of licenses and past employment as a pre-condition of employment. Furthermore, the Company may also make an investigation of my medical history and/or require a medical exam after a conditional offer of employment is made. I understand that the Company retains the right to verify my driving information with the DMV.

I authorize the giving and receiving of such information requested by the Company (including medical, licensign, worker's compensation, criminal and driving records) and hereby relieve and release former employers and their agents and licensing authorities, of any liability for any information they may give the Company. I hereby waive any all rights or claims against the Company, it's agent or employees arising out of, or resulting from te release of authorized or unauthorized information received pursuant to or in connection with the Company's handlintg, processing or investigation of my application.

I agree that if the Company emplyes me, all future potential employers may contact the Company or its representatives concerning my work record and work performance with the company. I hereby consent to and authorize persons employed by the Company to divulge any and all information they consider relevant to any person representing him or herslef to be an employer fo mine with respec to my work and/or performance of my job at the Company.

I understand and agree that, if hired, I will complete all educational courses and take all test necssary to keep my licenses current and valid required by the Company of local, state, and or federal law and regulations. I further agree to advise the Company if at any time my licenses become expired or invalid. I understand that failure to take such tests when required or requested or to keep licenses current and valid or to advise the Company that my licenses have expired or become invalid my result in my immediate dismissal

I agree to a physical examination if requested and/or if I receive a conditional offer of employment, including the analysis for the detection of use of illegal drugs or substances. I understand failure to meet any job related medical and/or health requirement for the position could prevent my employments of contiued employment with the Company.

I understand and agree that in the performance of my duties as an employee of the Company, or after I leave the Company, that I must hold in confidence any and all information that I come in contact with regaring my employer or its business.

I understand that this application will remain active ninety(90) days during which time it may, at the sole discretion of the Company be reviewed for open positions within the office at which I applied.

I have read and agree to the preceding Applicant Certification, Agreement and Release and rugher understand and agree that a copy of the Applicant Certification, Agreement and Release shall be valid as the original.

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