Employment Application Position Desired: * Required Location: * Required Personal Name: * Required First Last Address: * Required Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone: * Required Cell Phone: Email: * Required In case of emergency, Notify: Name * Required First Last Address: Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone: * Required Are you either a US citizen or an alien who is authorized to work in the US? * Required Yes No If yes, you must complete the I-9 Form required by the US Citizenship & Immigration Services no later than three (3) business days after your date of hire.Have you ever been convicted of a felony as defined by RIGL 21-17-37 that would disqualify you from working in healthcare? * Required Yes No As a condition of employment, ALL applicants are required to provide a fingerprint-based national background check from the Office of the Attorney General, 150 S. Main Street, Providence, RI.Have you ever served in the US Armed Forces? * Required Yes No Have you previously been employed by a Health Concepts, Ltd facility? (Laurel, Riverview, Village House, Elmwood, Morgan, Westerly, Bayberry, West Shore, S. Kingstown, Pine Grove, Woodpecker Hill, Heritage Hills, Eastgate?) * Required Yes No If yes, which location: * RequiredSelect oneBayberryEastgateElmwoodHeritage HillsLaurelMorganPine GroveRiverviewS. KingstownVillage HouseWest ShoreWesterlyWoodpecker HillStart Date: * Required MM slash DD slash YYYY End Date: * Required MM slash DD slash YYYY Job InterestHow did you learn of this job opening? * Required Date Available: * Required MM slash DD slash YYYY Salary/Rate Desired: * Required Work Hours: Full Time Part Time Per Diem Days Evenings Nights Weekends Educational RecordGrade School/High School: Highest Grade Completed * RequiredSelect one123456789101112College/Graduate: Highest Grade Completed * RequiredSelect one0123456Last High School: Last College/University/Nursing Schools: Graducate School: Technical or Vocational School: List courses in which you are curretnly enrolled:Professional Licensure/Certification(s)Type: State Issued: Date Issued: MM slash DD slash YYYY Expires On: MM slash DD slash YYYY Number: Have you ever held, or do you currently hold, a license in another state? * Required Yes No If yes, please list: * Required Have you ever held, or do you currently hold, a license in another name? * Required Yes No If yes, please list: * Required Are there any charges or investigations pending, in any state, against you? Have your staff privileges at any hospital, nursing home, or other health care facility, or health care provider or HMO ever been reduced, revoked, or suspended or have you voluntarily surrendered your clinical privileges from any such unit of facility while under investigation in any state? Have you ever had any disciplinary action(s) taken or is any pending against your license to practice nursing, or any other licenses, registrations or certifications that you hold, or are any complaints pending in any state? If the answer is yes to any of the above questions, please explain: * RequiredWork ExperienceMay we contact your present employer? * Required Yes No Is any additional information relative to change of name, use of an assumed name or nickname necessary to enable a check on your work and educational record? List your last/present employer first (including volunteer experience) and account for any lapse of time between employment. Employer 1:Employer Name: Employed From: MM slash DD slash YYYY To: MM slash DD slash YYYY Address: Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone: Position Title: Salary - Starting: Salary - Ending: Supervisor's Name: Supervisor's Title: Person(s) We May Contact: Briefly describe your duties:Reason for Leaving:Employer 2:Employer Name: Employed From: MM slash DD slash YYYY To: MM slash DD slash YYYY Address: Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone: Position Title: Salary - Starting: Salary - Ending: Supervisor's Name: Supervisor's Title: Person(s) We May Contact: Briefly describe your duties:Reason for Leaving:Employer 3:Employer Name: Employed From: MM slash DD slash YYYY To: MM slash DD slash YYYY Address: Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone: Position Title: Salary - Starting: Salary - Ending: Supervisor's Name: Supervisor's Title: Person(s) We May Contact: Briefly describe your duties:Reason for Leaving:References Please list the name of three (3) people that we may contact (other than current & past employers & family members)Reference 1 - Name: First Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How Known/Years Known: Phone: Reference 2 - Name: First Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How Known/Years Known: Phone: Reference 3 - Name: First Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How Known/Years Known: Phone: Health Concepts, Ltd. and its facilities are committed to the provision of equal employment opportunities to its applicants regardless of race, age, sex, religion, national origin, disability, color, creed, liability for service in the armed forces of the United States, citizenship or any other characteristic protected by applicable State and Federal Laws.Please Read the Following Carefully Before Submitting This Application Form:I understand that if hired my employment will be on a 90-day introductory basis, and that as long as I am employed by a Health Concepts, Ltd. facility, my employment may be terminated, with or without cause or notice, at any time, at my option or that of the facility. I understand that no management representative has any authority to enter into any agreement for continuing employment for any specific period of time that is contrary to the foregoing. I give Health Concepts, Ltd. and/or its facilities permission to contact any or all of my previous employers and references and authorize them to provide all information requested of them by the facility. I authorize Health Concepts, Ltd. and/or its facilities to obtain, use and rely upon that information in relation to my application and release Health Concepts, Ltd. and/or its facilities and all providers of such information from all liability in connection with the use of such information. I have provided truthful and complete responses to all inquiries in the application and understand that the discovery of any falsification or omission may disqualify me for further consideration for employment or result in my discharge from employment. If employed by Health Concepts, Ltd. and/or its facilities, I will abide by its rules and regulations which I understand are subject to change by Health Concepts, Ltd. and/or its facilities. If hired, I understand that commencement of employment is conditioned upon successful completion of a physical exam, employee orientation and background check.By clicking on "I accept", I acknowledge and consent that my electronic signature below is the equivalent of my manual signature. I accept Electronic Signature: * Required First Last Facility Email CommentsThis field is for validation purposes and should be left unchanged. Δ