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ONLINE APPLICATION

Thank you for your interest in joining MediTech Health Services, Inc. Please fill
out all pages of the application for employment prior to your interview. You may
attach a resume, but you must complete the application. MediTech Health
Services, Inc. is an equal opportunity employer. Your Application will be
considered without regard to race, color, creed, age, sex, national origin, or
disability.

 
Name
Date Of Birth
Email address
Phone
Mailing Address
Secondary Phone
US Citizen



Current Address
If you are not a US citizen, what type of visa do you have?
How Did You Hear Of MediTech
Foreign Languages
Date Available
Former Employee



EDUCATION:
DEGREE/DIPLOMA
MAJOR
SCHOOL NAME & STATE
DATES ATTENDED
NURSING SCHOOL
UNIVERSITY
JR/TECH COLLEGE
HIGH SCHOOL






Other Degree
1. Have you ever been barred from practice of your profession at any time or has your professional license ever undergone investigation, suspension, or revocation? 
2. Have you ever been convicted of a felony?



3. Have you ever been convicted of Medicare or private insurance fraud?



4. Have you ever been the defendant in malpractice litigation?



 
IF YOU ANSWERED YES TO ANY OF THESE FOUR QUESTIONS, PLEASE EXPLAIN ON A SEPARATE, SIGNED SHEET OF PAPER.
 

PROFESSIONAL CREDENTIALS / CERTIFICATIONS
LICENSE/CERT. NUMBER
STATE
EXP DATE
REFERENCES
LIC #
(List two (2) references, not related to you, whom you have been acquainted with professionally for at least one year.)
LIC #
#1 Name, Address, Phone, Yrs Acquainted

CPR #

PALS #

NALS #

ACLS #
#2 Name, Address, Phone, Yrs Acquainted
CCRN #
CHEMO #
NRP #
OTHER #
     

EMPLOYMENT HISTORY: (List your experience over the past 7 years; begin with your current or last employer)

EMPLOYER:

ADDRESS:

PHONE NUMBER:

POSITION:

STARTING / ENDING SALARY:

JOB RESPONSIBILITIES:
SUPERVISOR’S NAME & TITLE: START DATE:
PHONE NUMBER: END DATE:
MAY WE CONTACT YOUR EMPLOYER?  


 
EMPLOYER:
ADDRESS:
PHONE NUMBER:
POSITION:
STARTING / ENDING SALARY: JOB RESPONSIBILITIES:
SUPERVISOR’S NAME & TITLE: START DATE:
PHONE NUMBER: END DATE:
MAY WE CONTACT YOUR EMPLOYER?  


 
EMPLOYER:
ADDRESS:
PHONE NUMBER:
POSITION:
STARTING / ENDING SALARY: JOB RESPONSIBILITIES:
SUPERVISOR’S NAME & TITLE: START DATE:
PHONE NUMBER: END DATE:
MAY WE CONTACT YOUR EMPLOYER?  


 
   

I authorize MediTech Health Services, Inc. to investigate my employment history, credentials, personal character, habits, abilities, and health and obtain any relevant information (including a criminal and abuse background check) needed to make my employment decision. I authorize MediTech Health Services to disclose this application along with any information about me obtained through reference checks or during the course of the interview process for state, federal, contractual or accreditation audit purposes; this also includes disclosure of any of my performance appraisals, disciplinary records or skills tests for the same purpose as above. I release MediTech Health Services, Inc. and any individual or entity providing information to MediTech Health services from all liability for any damages from the disclosure of this information.  I understand and agree that, if hired, my employment is for no definite period and is based on the mutual consent. Accordingly, the employment relationship can be terminated at will, with or without advance notice, at any time.  I certify that the information contained in this application is true, and I understand that any misrepresentation or willful omission of the facts is cause for immediate termination.
Name Date

WORK AVAILABILITY:

  

Based on at least one year current and relevant experience is required. 

What are the areas you prefer to work?

What shift do you prefer?





Other

1st
2nd
3rd
4th
       
Are you applying for a traveling nurse assignment?



If so, how many weeks would you prefer the assignment to be?

 
       
     
Send Form To MediTech HR Dept.