Employment Application

Position Applied For

Available Start Date

Desired Hourly Pay Rate

Desired Employment

Full Time Part Time Seasonal

Have you previously submitted an application to this company?

Yes No

Have you previously worked for this company

Yes No

If hired, can you furnish proof that you are eligible to work in the United States?

Yes No

Will you work overtime or weekends if required for this position?

Yes No

Employment History (Most Recent)

Summarize work performed

What did you like the most about this job?

May we contact this employer for a reference

Yes No

Summarize work performed

What did you like the most about this job?

What did you like the least about this job?

May we contact this employer for a reference

Yes No

Summarize work performed

What did you like the most about this job?

What did you like the least about this job?

May we contact this employer for a reference

Yes No

Education (most recent first)

Relationship (non relatives)

Have you ever been fired from a job or asked to resign?

Yes No

If yes, please explain

Please list any special training, skills, certificates or licenses that may qualify you for the position for which you are applying

Please list any special recognition in past employment, such as for project accomplishments or awards

Please list any supervisory experience

Have you been convicted of a felony?

Yes No

If yes, please explain

Have you been convicted of any misdemeanor?

Yes No

If yes, please explain

Are you presently formally charged with committing a criminal offense? (Do not include any traffic violations, juvenile offenses or military convictions, except by general court-martial)

Yes No

If yes, please explain

Have you ever knowingly used any controlled substances other than those prescribed to you by a physician?

Yes No

If yes, please explain

Have you ever been bonded?

Yes No

If yes, please explain

Clinical Positions Only

Have you ever been the subject of a license, registration (i.e., DEA, State controlled substances registration) or certification (i.e., PTCB) disciplinary action?

Yes No N/A

If yes, please explain

Are any charges currently pending against your license, registration or certification?

Yes No N/A

If yes, please explain

Is your license or certification currently active and in good standing?

Yes No N/A

If no, please explain

Have you ever been excluded by any government authority (i.e., U.S. Department of Health and Human Services Office of Inspector General) from participation in any federal (i.e., Medicare) or state (i.e., Medicaid) health care program?

Yes No N/A

If yes, please explain

Have you ever been excluded by any commercial insurance plan or pharmacy benefit manager from participation in a provider network or otherwise from providing services to program beneficiaries?

Yes No N/A

If yes, please explain

Have you ever been named as a defendant in a professional liability lawsuit?

Yes No N/A

If yes, please explain

Have you ever been denied any policy of professional liability insurance?

Yes No N/A

If yes, please explain

Please upload your current resume

Authorization

I certify that all information I have provided within or attached to this application is true, correct and accurate. I understand that any information provided by me that is discovered to be false, incomplete or misrepresented in any respect will be sufficient cause to eliminate me from further consideration for employment, or may result in immediate termination from the employer’s service if discovered after hire. I authorize the employer, its representatives, employees or agents to contact and obtain information from all references, employers, government and public agencies, licensing authorities and educational institutions and to verify the accuracy of the information I have provided in or attached to this application, résumé or interview. I waive any and all rights and claims I may have regarding the employer, its agents, employees or representative for seeing, obtaining and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing information about me. I understand that this employer is an EEO employer who does not lawfully discriminate in employment and that no question on this application is used for the purpose of limiting or eliminating an applicant from consideration for employment on any basis prohibited by applicable local, state or federal law. If hired, I agree to conform to the company’s rules and regulations. I agree that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at either my or the company’s option. I understand that this application is current for 30 days from the date it is completed. To be considered for employment after that time period, I will have to complete another application. I understand that if I am hired, I will be required to provide proof of my identity and legal authorization to work in the United States and that federal immigration laws require me to complete an I-9 Form within three (3) working days after hire. I authorize Triad Care, Inc., to make any inquiry necessary of courts and law enforcement agencies for possible pending charges or convictions. I understand that information furnished or recovered as a result of any inquiry will not necessarily preclude employment, but will be considered as part of an overall evaluation of my qualifications. I understand that any false information or omission of information on the Employment Application or this questionnaire will jeopardize my position with respect to employment. I certify that I have read, understand and accept all the terms of the above applicant information.

Electronic Signature

Employment Application

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