Employment Application

Licensure/Certifications

Current Licensure/Certification *

License # *

State *

Expiration Date *

License #

State

Expiration Date

Insurance

Malpractice Insurance Company Policy # *

Effective Date *

Expiration Date *

Job Interest

Position Desired *

Date Available *

Indicate clinical preferences

Attach Resume *

Maximum upload size: 2.1MB

Education and Training

Name of Post-Secondary School *

Years Attended *

List Diploma, Degree or Course of Study *

Instructors to contact or educational reference

Name

Mailing Address

Phone

Special honors, awards, internships, certifications

Membership in professional organization

Education and Career Goal

Employment History (most recent employer first)

Company Name *

Employed *

Yes

Address *

Address

Position Held *

Supervisor *

Salary *

Type *

Full Time

Part Time

Reason for Leaving *

May we contact for refrence *

Yes

Individual to contact for reference (include title)

Duties

As the applicant, I hereby authorize SAMARITAN SERVICES, Inc. may request, within one year of my signing of this application, any and all pertinent information concerning my prior employment and its termination, including reasons for such termination from all prior employers.

I certify that answers given are true. I authorize investigation of my statements and a criminal background check to be completed. False or misleading information may result in my discharge. I understand I am required to abide by the rules and regulations of the agency. I also understand that the agency is an Equal Opportunity Employer, and all applicants are considered for all positions without regard to race, color, religion, sex, national origin, age or marital status.

Applicant's Signature *

Clear

Date *

Personal

Licensure/Certifications

Insurance

Job Interest

Education and Training

Employment History (most recent employer first)

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