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Medical Staffing | LRS Healthcare Medical Staffing | LRS Healthcare JCAH

Application Form
Personal Information
First Name
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Middle Initial
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Last Name
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Street : Apt #: City : State : Zip Code :
Address :
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Email: Phone: Birthdate: Social Security # Desired Salary (x/HR)
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Position Applied For:
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Are you a citizen of the United States?

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If no,are you authorized to work in
the United States?
 

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Have you ever worked for this company?

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If yes, when? 
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Have you been convicted of a felony within the last 7 years?
(Applicants are not obligated to disclose a sealed juvenile
record, which includes records of: an arrest, being taken into
custody, a complaint, disposition of a case, diversion or
adjudication of a criminal charge, or a sentence following
conviction). Conviction will not necessarily disqualify applicant
from employment. The recency, severity, and pertinence
of the conviction to the job will all be considered.


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If yes, explain? 
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Education
School Attended: Address: Dates Attended: Graduate: Degree:
High School:
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College:
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Other:
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References
Reference #1 Reference #2 Reference #3
Full Name:
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Relationship:
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Company:
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Phone:
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Address:
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Previous Employment
Previous Employer #1 Previous Employer #2 Previous Employer #3
Company:
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Phone:
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Address:
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Supervisor:
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Job Title:
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Starting Salary:
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Ending Salary:
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Dates of Employemnt:
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Reason for Leaving:
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May we contact your previous supervisor for a reference?

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License / Certifications
States(s):
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Dates of Licensure (From / To)
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License #:
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Expiration Date:
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List Certifications (BCLS, ACLS, NRP, PALS, etc. & Expirations)
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Has your professional license ever been investigated or suspended?

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If yes, why?
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Have you ever been named as a defendent in a professional liability claim?

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If yes, explain?
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Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

I hereby authorize LRS Healthcare, to release any and all professional credentials, work verifications, and/or health information that have been acquired by LRS Healthcare. I understand this information will be sent only to the clients where I will be presented for potential assignment and/or working as an LRS Healthcare employee, for the purpose of assuring that all required credentials and regulatory documentation as required by contract are in place and current prior to and during my assignment. I hereby release LRS Healthcare and affiliates, schools, companies, former employers, and all other persons named from all liability for any damages resulting from issuing this information.

Please enter your name in the box below. By doing so you are hereby certifying that you are indeed the person listed above and signing this form.

PLEASE NOTE: By clicking the Submit button below, your IP Address will be recorded and this provides a means to verify your identity.
Electronic Signature (Enter your full name)
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Date: 
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Submit your Resume:
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