Full Application

Found your dream job? Complete our Full Application and we'll contact you shortly. Or if you prefer, call or email us for immediate attention.

Part 1: Personal Information

Email Address:

Date:

/ /

First Name:

Last Name:

Current Address:

City:

State:

Zip Code:

If your current address differs from your permanent address, please fill out the following as well:

Permanent Address:

City:

State:

Zip Code:

Home Phone:

( ) -

Cell Phone:

( ) -

Pager:

( ) -

Work Phone:

( ) -

Are you over the age of 18? Yes No

Part 2: Emergency Contact

Name:

Relationship

Telephone:

( ) -

Cell Phone:

( ) -

Part 3: Legal

Are you a citizen of the U.S. or do you have the legal right to be employed in the United States?

Yes No

Alien Registration Number (Visa #)

Expiration date

/ /

Type of Card

Have you ever been convicted of any crime excluding minor traffic violations?

Yes No

If yes, please explain:

Note: A conviction will not necessarily disqualify you from employment.

Do you have the ability, with or without reasonable accommodations, to do the job which you are applying ?

Yes No

Part 4: Professional and License Information

Professional Discipline:

PT OT SLP-CCC PTA COTA School Nurse

School Psychologist Social Worker Special Education Teacher

Specialty Skills/Areas:

Original State of Licensure:

License #:

Expiration Date:

/ /

Please List all additional states you hold an active license:

License #:

Has any license/certification been subject to disciplinary action or investigated

Yes No

If yes, Explain:

List all states which you have an applied status for a license:

Date Applied:

/ /

Date Applied:

/ /

Date Applied:

/ /

Date Applied:

/ /

Date Applied:

/ /

Part 5: Education

	Education level	Name/Location of School	Graduation Date (Month/Year)	Type of Diploma/degree
College			/
Graduate School			/
Other School			/

Part 6: Employment History

Please fully complete the following section even if application is accompanied by a professional resume.

Starting with your most current job, list all positions held for the past ten (10) years. Give current and correct telephone numbers and addresses.

Name of most current or recent employer

Address		City
State		Zip Code
Phone	( ) - ext
Supervisor Name		Supervisor's Title
Dates of Employment:	From: / / To: / /
Starting Salary:		Final Salary:
Position Held:		Reason for Leaving:
Was this a temporary or travel assignment?		Yes No
		If yes, which agency:
Job Responsibilities:

Name of second most recent employer

Address		City
State		Zip Code
Phone	( ) - ext
Supervisor Name		Supervisor's Title
Dates of Employment:	From: / / To: / /
Starting Salary:		Final Salary:
Position Held:		Reason for Leaving:
Was this a temporary or travel assignment?		Yes No
		If yes, which agency:
Job Responsibilities:

Name of third most recent employer

Address		City
State		Zip Code
Phone	( ) - ext
Supervisor Name		Supervisor's Title
Dates of Employment:	From: / / To: / /
Starting Salary:		Final Salary:
Position Held:		Reason for Leaving:
Was this a temporary or travel assignment?		Yes No
		If yes, which agency:
Job Responsibilities:

Personal references:

	Name	Telephone	Occupation
1.		( ) - ext
2.		( ) - ext
3.		( ) - ext

Part 7: Upload your resume

Please attach you resume in an MSWord ".doc" or any other word processors ".rtf" file type by clicking the "Browse" button below.

Attach Resume:

Please read the following before submitting this application

I hereby certify that the information I have provided in this application form is true and correct to the best of my knowledge. I understand that if I am employed, any false, misleading or otherwise incorrect statements made on this application or during my interviews may be grounds for my immediate discharge.

I agree to allow Prime HealthCare Staffing to verify the accuracy of all the information provided including contacting any company or individual it deems appropriate to verify my employment history, character and professional qualifications.

I understand stand my employment with Prime HealthCare Staffing is at will and may be terminated by myself or by the company at any time for any reason or no reason, with or without prior notice.

I have read and agree to the above statements.

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