License
Licensing Authority/ State Board:*    
License number:*    
Expiration Date:*    
Date of Issue:*    
Type of License:*
RN  PT  OT  ST  MSW 
Have you passed the IELTS?*
Yes  No 
Have you passed the NCLEX?*
Yes  No 
Have you passed the TOEFL?*
Yes  No 
Have you passed the TSE?*
Yes  No 
Have you passed the CGFNS?*
Yes  No 
Are you currently a Registered?*
Yes  No 
Current malpractice insurance carrier name and address:    
Current malpractice insurance carrier policy number:    
Personal Information
First Name:*    
Last Name:*    
Gender:*    
Social Security Number*    
E-Mail:*    
Address Line 1:*    
Address Line 2:    
City:*    
State:*    
Zip Code:*    
Home Phone:*    
Business Phone:    
Cell Phone:    
Work Preference
Date Available:*    
Postion Applied For:*    
Minimum Acceptable Anual Salary:*   Numerals only please
Employment Requested:*
Full Time
Part Time
Temporary
Education
High School Name/Location:    
Diploma Received:*
Diploma
Equivalency
None
College Name/Location:    
Degree Earned:    
Attended from:   MM/DD/YYYY
Attended To:   MM/DD/YYYY
Major/Minor:    
College Name/Location:    
Degree Earned:    
Attended from:   MM/DD/YYYY
Attended To:   MM/DD/YYYY
Major/Minor:    
Employment History
Name Of Employer:*    
Address Line 1:*    
Address Line 2:    
City:*    
State:*    
Zip Code:*    
Employed From:*   MM/DD/YYYY
Employed To:*   MM/DD/YYYY
Employer Phone:*    
Job Title:*    
Supervisor Name:*    
Reason For Leaving:*    
Name Of Employer:    
Address Line 1:    
Address Line 2:    
City:    
State:    
Zip Code:    
Employed From:   MM/DD/YYYY
Employed To:   MM/DD/YYYY
Employer Phone:   Supervisor phone preferred
Job Title:    
Supervisor Name:    
Reason For Leaving:    
Related Knowledge/Skills:*   1000 characters or less
Professional References
Please list three references that have knowledge of your professional experience.
Reference Name:*    
Address:*    
Occupation:*    
Phone:*    
Reference Name:*    
Address:*    
Occupation:*    
Phone:*    
Reference Name:*    
Address:*    
Occupation:*    
Phone:*    
Background
HAVE YOU EVER BEEN CONVICTED OF A FELONY OR A FIRST DEGREE MISDEMEANOR?
*
Yes
No
HAVE YOU EVER PLED NO CONTEST OR GUILTY TO A FELONY OR A FIRST DEGREE MISDEMEANOR?
 
Yes
No
ARE YOU A U.S. CITIZEN OR ARE YOU LEGALLY AUTHORIZED TO WORK IN THE U.S.?
*
Yes
No
Has your professional license or certification ever been investigated or suspended?
*
Yes
No

I certify that the information in this application is accurate and complete. I understand that misstatements or omissions may result in disqualification from further consideration or termination of employment. I authorize United Caregivers, Inc to conduct investigations which information may be obtained through personal interviews with business associates, personal acquaintances, financial sources or other third party regarding my employment history, credentials, character and credit background and to obtain any relevant information (including a criminal background check and consumer report) needed to make a decision. I authorize United CareGivers, Inc to disclose this application along with any information about me obtained through reference check or during the course of the interview process for local, state, federal contractual or accreditation audit purpose. I also authorize United CareGivers, Inc to disclose any of my performance appraisals, disciplinary records or skills tests for the same purpose as above. I release United CareGivers, Inc and any individual or entity providing information to United CareGivers, Inc from liability for any damages from the disclose of this information. I also understand and agree that:

passing a medical examination and/or participating in a post-conditional offer medical screening may be required. If medical restrictions cannot be reasonably accommodated I may not be hired, or if hired, employment may be terminated.

* I may be subject to pre-employment drug testing, or a drug test where a reasonable suspicion exists, or where warranted by circumstances, workplace conditions or contractual requirements.

* I understand and agree that nothing contained in this employment application or in granting of an interview creates an employment contract between United CareGivers, Inc and myself for either employment or for the providing of benefit. No promises regarding employment have been made to me. If an employment relationship is established, I understand that my employment will be terminable "at will", that I will have the right to terminate my employment at any time, and that United CareGivers, Inc maintain a similar right to terminate my employment at any time. I understand and agree that this application is a continuous document and should any of the information which I have supplied herein change, I am obligated to notify United CareGivers, Inc of such change immediately. I understand that should I become employed by United CareGivers, Inc my work assignments, schedules and/or work locations are subject to change according to the needs of the business and the clients of United CareGivers, Inc.

I also understand and agree that during the application process and at any time during any subsequent employment, I hereby authorize United CareGivers, Inc procure a consumer report which I understand may include information regarding my character, general reputation, personal characteristics, or mode of living. This report may complied with information from courts record repositories, department of motor vehicles, past or present employers, verify information that I have voluntarily supplied. I understand that if any inquiry is made, more information as to the nature and scope of the inquiry will be supplied to me upon my written request. Copies of this document can be used in lieu of the original. I have been given a stand alone, consumer notification that a report will be requested and used for the purpose of evaluating me or employment, promotion, assignment or retention as an employee.