Application Form | Summit Healthcare Staffing LLC

Employment Application Form
Date *
Month Day Year
Date
Name *
First Name Middle Name Last Name
Phone Number *
Please enter a valid phone number.
Email *
[email protected]
Address *
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Preferred City / Location to Work
Please check where applicable
What position are you applying for? *
RN LPN QMA CNA
What schedules would you prefer? *
Full Time Part Time Temporary Week Days Evenings Nights
How did you know About Us *
Walk in Referral Online
Name of the person who reffered you
Have you worked for this company before? *
Yes No
Date ( From ) *
Month Day Year
Date
Date ( To ) *
Month Day Year
Date
Desired Pay: $ (Per hr) *
When are you able to start to work? *
In compliance with the law, Federal law requires that employers hire only individuals who are authorized to be lawfully employed in the United States. Before employment offer, Summit Health Care Agency will verify eligibility to legally work in the United States. Proof will be required in form of documents as required by law to verify your identification and employment authorization. Summit Health Care Agency complies with all applicable federal, state and local laws governing non-discrimination in place of employment. Summit Health Care Agency is an equal opportunity employer and does not discriminate against based on race, color, religion, sex, national origin, disability,age, or military or veteran status.
Are you able to legally work in the United States? *
Yes No
A felony conviction record will not necessarily bar you from employment
Have you ever been convicted of a felony *
Yes No
Please Explain
Are you under 18 years of age? *
Yes No
Can you provide a work permit? Securely Upload here

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Able to perform duties for the position you are applying for without any special accommodation? *
Yes No
please explain if any accommodation is needed
Work Experience
Employer #1 *
Your position and title *
From *
Month Day Year
Date
To *
Month Day Year
Date
Supervisor's Name *
Supervisor's Phone Number *
Please enter a valid phone number.
Company Street Address *
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Employer #2
Your position and title
From
Month Day Year
Date
To
Month Day Year
Date
Supervisor's Name
Supervisor's Phone Number
Please enter a valid phone number.
Company Street Address
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Employer #3
Your position and title
From
Month Day Year
Date
To
Month Day Year
Date
Supervisor's Name
Supervisor's Phone Number
Please enter a valid phone number.
Company Street Address
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
EDUCATION (Most Current First)
EDUCATION (Optional)
Professional Licenses
Professional Licenses
References ( All 3 Required)
Reference 1 *
Reference 2 *
Reference 3 *
BY SIGNING THE APPLICATION: I acknowledge that the purpose of this application is obtaining temporary employment and it does not indicate that any positions are open, nor Summit Health Care Agency is obligated to further process my application. By signing the application I certify my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misguiding information in my application or interview can be justification for refusal of employment.I acknowledge that this application is not an employment contract between Summit Health Care Agency and me. I understand once hired, my employment will be “at will” and either Summit Health Care Agency or I can terminate my employment at any time with or without cause or notice.I hereby authorize the Summit Health Care Agency and its appointed agents to contact my references to make any inquiries. If employed I understand I am Summit Health Care Agency employee and not of any Summit Health Care Agency client. I understand that my employment is not guaranteed for any specific time and may be terminated at any time for any reason. I further understand in the event I accept employment with any of Summit Health Care Agency client, I need to notify Summit Health Care Agency immediately. In such a case the client will be required to pay a fee as agreed between Summit Health Care Agency and the client.
(I understand by signing or typing my full names below count as a legal signature).
Signature

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Or
Name *
First Name Last Name
Date *
Month Day Year
Date
To expedite hiring process please attach the following with your application
1) Copy of Social Security Card
2) Copy of State Driver License
3) A recent employment physical
4. A copy of your current TB test or Chest X-ray
5) A copy of your current CPR card
6) TB certification Card
7) Proof to work in the United States ( passport or Green card)
Upon receipt of your application and the above documentation, Summit Health Care Agency will set up an interview appointment. We look forward to having you in our team.
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Authorization for background check
I agree the Company may rely on this authorization to order background reports, including investigative consumer reports, from companies other than the Background Check Company without asking me for my authorization again as allowed by law. I also agree that a copy of this form is valid like the signed original. I certify that all of the personal information I provided is true and correct.
Name *
First Name Middle Name Last Name
Maiden/Other Names
Years used
I understand by signing or typing my full names count as a legal signature.
Signature

Clear
or.
Name *
First Name Last Name
Date *
Month Day Year
Date
Drug/ Alcohol Testing Consent Form.
Name *
First Name Last Name
I do hereby give my consent to authorize my employer known as America’s First Choice Nursing Staffing LLP (Summit Health Care Agency) and the testing laboratory designated to conduct analytical tests deemed necessary, on an ongoing basis, to determine the absence or the presence of Alcohol, Class A Drugs (heroin, cocaine, etc.), Class B Drugs (cannabis, amphetamines, etc.) in my body using urine, hair, blood, breath or any sample as specified by statute and regulation. I give my consent to release the results of the test(s) and other medical information from the laboratory to my employer pursuant to statute or regulation with the condition that the results may not be used in any criminal proceeding. My employer may request proof that I am taking a controlled substance as directed pursuant to a lawful prescription issued in my name. If requested, I agree to provide such proof within 72 hours.I have the right to request a re-test of the initial specimen at a licensed laboratory of my choice if and when I have a positive test for drugs. All requests for a re-test of the sample must be made within ten (10) working days of the receipt of the original positive test result. The results of the samples must be forwarded to me by the appointing authority of the licensed laboratory. I further understand that a positive test, refusal to authorize this form, refusal to take the test, or failure to produce a specimen, may result in disciplinary action up to and including dismissal in accordance with any local, State, or Federal statute, regulation, and policy. Employee’s Signature
[ I understand by signing or typing my full names below count as a legal signature] *
I understand by signing or typing my full names on these and all attached documents count as a legal signature.
Signature

Clear
or.
Name *
First Name Last Name
Date *
Month Day Year
Date
SUMMIT HEALTHCARE STAFFING
AUTHORIZATION FOR BACKGROUND CHECK
(Please read and sign this form in the spaces provided below. Your written authorized is necessary for completion of the application process)
I blanks hereby authorized Summit healthcare staffing to investigate my background and qualification for purpose of evaluating whether I am qualified for the position for which I am applying. I understand that Summit healthcare staffing will utilize an outside firm or firms to assist it in checking such information, and I specifically authorized such an investigation by information service and outside entities of the company's choice. I also understand that I may withhold my permission and that in such a case, no investigation will be done, and my application for employment will not processed further.
Name *
First Name Middle Name Last Name
Other Names/Alias (Married. Maiden)
Social Security# *
Date of Birth *
Month Day Year
Date
Sex *
Male Female N/A
Race/Ethnicity *
American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander
Signature *

Clear
Date *
Month Day Year
Date
Facility instructions: Use the above information to complete the Criminal History Check Form. Place this copy in the Employee's personnel file
HIPPA ACKNOWLEDGEMENT OF CONFIDENTIALITY OF PATIENT CARE INFOMATION.

I acknowledge the confidentiality of patient healthcare information (confidential patient information) that i recieve or have access to in the course of providing patient care services at the healthcare institution at which I am assigned through summit healthcare staffing.
I shall maintain the confidentiality of confidential patient information, and in doing so shall comply with all applicable state and federal laws and regulations, including without limitation, the privacy provisions under the health insurance portability and accountability Act of 1996 "HIPAA" and the policies and procedures of each healthcare institution I am assigned to.
My agreement to maintain the confidentiality of confidential patient information shall survive the termination of my employment with summit healthcare staffing and the conclusion of any assignment at the healthcare facility through the same.
Name
Signature *

Clear
Date *
Month Day Year
Date
Bloodborne Pathogens
I have been informed of the symptoms and modes of transmission of bloodborne pathogens including Hepatitis B virus(HBV).I know about the facility's Infection Control Program and understand the procedure to follow if an exposure incident occurs.
I understand that Hepatitis B vaccine is available, at no cost to employees whose job involves the risk of directly contacting blood or other potentially infectious material.I understand that vaccination will be given per the recommendations for standard medical practice in the community.
I understand that the election/declination to obtain the Hepatitis B vaccine is my choice and that I have not been influenced by anyone from Summit healthcare Staffing.
Hepatitis B vaccine Election.
Signature of employee *

Clear
Employee Name
HEPATITIS B VACCINE DECLINATION.
Signature of employee *

Clear
Date *
Month Day Year
Date
Employee Name
TB Signs & Symptoms Questionnaire
Name
Birth Date *
Month Day Year
Date
Date of last Chest X Ray: *
Month Day Year
Date
Since you have had a positive PPD and are now required to have a chest x-ray every 5 years, the following is to be completed annually and maintained in the personnel file.

Please read and put a checkmark in the correct Yes/No space if you are experiencing any of the following symptoms or if any of the following apply to you.Type a question

	YES	NO
1. Unplanned loss of weight (>10 % of body weight)
2. Night sweat
3. Fever lasting several weeks
4. Frequent coughing in the absence of cold or flu
5. Coughing blood-streaked sputum
6. Unusual tiredness or weakness lasting weeks
7. Pain in chest when taking breath
8. Have you recently been diagnosed with diabetes, silicosis, HIV disease,renal disease or liver disease?
9. Have you been recently exposed to a family member Or others with active TB?

If you checked yes to any of the above questions, are you currently being treated by a physician?
If yes, please explain:
IF YOU DEVELOP ANY OF THE SYMPTOMS LISTED ABOVE PLEASE CONTACT YOUR PHYSICIAN AND AGENCY IMMEDIATELY. A CHEST X RAY MUST BE PERFORMED PRIOR TO WORKING AGAIN.
Employee Signature *

Clear
Date *
Month Day Year
Date
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Employment Application Form

Please check where applicable

A felony conviction record will not necessarily bar you from employment

Work Experience

EDUCATION (Most Current First)

References ( All 3 Required)

Or

Authorization for background check

or.

Drug/ Alcohol Testing Consent Form.

I understand by signing or typing my full names on these and all attached documents count as a legal signature.

or.

Hepatitis B vaccine Election.

HEPATITIS B VACCINE DECLINATION.

TB Signs & Symptoms Questionnaire