RTP Application Please download and send the application to rt@staffhospital.com or fill out the application below Name * First Name Last Name Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * Country (###) ### #### Social Security Number * Date of birth * MM DD YYYY Specialty * STATE LICENSURE State * License Number * Expiration Date MM DD YYYY CERTIFICATIONS Certification Number * Expiration Date * MM DD YYYY Has your license or certification ever been investigated or suspended? * Yes No Have you ever been convicted of a crime other than a minor traffic violation? * Yes No Have you ever been named as a defendant in a professional liability action? * Yes No EDUCATION INFORMATION College/University * Date Graduated * MM DD YYYY Diploma/Degree * Graduate School Date Graduated MM DD YYYY Degree EMPLOYMENT HISTORY Are you currently employed? * Yes No If so, may we contact your current employer? Yes No Beginning with your current or most recent employer, please list your last two positions held 1. Facility/Hospital Name * Department * Date Employed * Date Start MM DD YYYY Date Employed End Date MM DD YYYY Reason for leaving Job Position * Supervisor Name/Title * Supervisor Phone * Country (###) ### #### Travel Assignment? * Yes No 2. Facility/Hospital Name * Department * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date Employed Start Date MM DD YYYY Date Employed End Date MM DD YYYY Reason for leaving Job Position Supervisor Name/Title Supervisor Phone Country (###) ### #### Travel Assigment? Yes No EMERGENCY CONTACT Emergency Contact Name * First Name Last Name Relationship * Phone * Country (###) ### #### Available Date * MM DD YYYY ACKNOWLEDGEMENT (Please read carefully and sign) In signing this application, I certify that I have read and fully understand the questions asked in this application and that all answers given by me are true, accurate, and complete. I give RTP Healthcare Staffing permission to use any information in this application to enable it and its agents to verify the information contained in this application I also authorize present and former employers, educational institutions I have attended, credit agencies, all references, and any other persons to answer all questions asked by RTP Healthcare Staffing with regard to any of the subjects covered by this application. I also understand that in connection with my application for employment or my employment, RTP Healthcare Staffing may conduct a criminal background investigation and that my employment may be contingent on the results of such investigation I release. I understand and acknowledge that: I shall respect and maintain the confidentiality of all discussions, deliberations, patient care records and any other information generated in connection with individual patient care, risk management and/or peer review activities. It is my legal and ethical responsibility to protect the privacy, confidentiality and security of all medical records, and other confidential information relating to RTP Healthcare Services. I hereby acknowledge that I have read and understand the foregoing information and that my signature below signifies my agreement to comply with the above terms. Signature (last 4 digit of your ss#) * Date MM DD YYYY AUTHORIZATION, CONSENT AND RELEASE FOR BACKGROUND INFORMATION Understand that in conjunction with my application for employment, RTP will use the services of an outside agency to research and verify the information I have provided on my application for employment including my personal background, character, professional standing, work history and qualifications. This agency will provide a written report of its findings to RTP. The investigation agency will utilize various sources of information it deems appropriate including but not limited to: credit reporting agencies, workers Compensation records including any and all injuries in compliance with the Federal ADA Act, Department of Motor Vehicle records, criminal convictions, current and former employers, military records, education records, professional and personal references. I request, authorize and consent to the release and disclosure of any and all information including but not limited to the above to RTP and the investigation agency. I request, authorize and consent to the procurement of an Investigative Consumer Report and/or Consumer Credit Report and understand that they may contain information about my background, mode of living, character, personal characteristics and general reputation. This authorization in original or copy form shall be valid for one year from the date indicated next to my signature. According to the Fair Credit Reporting Act, I will be notified by RTP if employment is denied because of information obtained from a Consumer Reporting Agency. Additionally, I understand that if requested within 60 days, I will be given a full and accurate disclosure as to the nature and substance of all information provided to RTP. I further understand that when requesting a copy of the report, proper identification will be required and I should direct my request to the investigation agency. LAW ENFORCEMENT AGENCIES AND OTHER ENTITIES FOR POSITIVE IDENTIFICATION PURPOSES REQUIRE THE FOLLOWING INFORMATION WHEN CHECKING PUBLIC RECORDS. IT IS CONFIDENTIAL AND WILL NOT BE USED FOR ANY OTHER PURPOSES. I HEREBY RELEASE RTP ITS AGENTS, AND ALL PERSONS, AGENCIES, AND ENTITIES PROVIDING INFORMATION OR REPORTS ABOUT ME FROM ANY AND ALL LIABILITY ARISING OUT OF THE REQUEST FOR OR RELEASE OF ANY OF THE ABOVE-MENTIONED INFORMATION OR REPORTS. Name * First Name Last Name PLEASE PROVIDE ALL RESIDENTIAL ADDRESSES FOR THE PAST 7 YEARS Address Address 1 Address 2 City State/Province Zip/Postal Code Country Address Address 1 Address 2 City State/Province Zip/Postal Code Country Address Address 1 Address 2 City State/Province Zip/Postal Code Country Signature (Last 4 digit of your ss#) * Date * MM DD YYYY Please attach: Resume, Licenses, CPR Card, TB/ PPD test, Covid Vaccine, Driver License, Immunization record Upload File: UPLOAD Thank you for your application! We appreciate your interest and will be in touch soon. Employment Application or
