Please note: required fields marked with an asterisk (*).
First Name:*		Last Name:*
Address:*		City:*
State:*		Zip:*
Phone:*		Alt. Phone:
Emergency Contact:		Emergency Contact Phone:
E-mail:		Social Security Number*:
Position Applying For:	RN NP LPN CNA TECH PT OT OTHER
Other:

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Have you ever applied or worked for DirectMed Health Services?		Yes		No
Have you ever lost any certification/license/registration?		Yes		No
Have you ever been convicted of a crime?		Yes		No
Are you under investigation by any licensing body?		Yes		No
If you have answered 'Yes'  to any of the above, please explain below. DirectMed considers full details & circumstances of any incident.

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Education
	School Name	City, State	Degree, Diploma, Certificate	Dates Attended
High School
College
Post College/Grad
Trade/Vocational

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Employment History
Employer:
Address:		City:
State:		Zip:
Phone:		Salary:
Supervisor:		May we contact this employer?	Yes No
Dates of Employment:	From: To:	Reason for Leaving:

Employer:
Address:		City:
State:		Zip:
Phone:		Salary:
Supervisor:		May we contact this employer?	Yes No
Dates of Employment:	From: To:	Reason for Leaving:

Employer:
Address:		City:
State:		Zip:
Phone:		Salary:
Supervisor:		May we contact this employer?	Yes No
Dates of Employment:	From: To:	Reason for Leaving:

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Agency Work Experience
Agency Name	City, State	Dates of Employment	Name of Healthcare Facilities where you have worked

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What type of assignment are you available for?	Full time Part time Travel Contract	What shift do you prefer to work?	7am-3pm 3pm-11pm 11pm-7am 7am-7pm 7pm-7am other
Other:
What days of the week are you available? (Hold down Ctrl key to select multiple days)	Sunday Monday Tuesday Wednesday Thursday Friday Saturday	Are you available to work:	Weekends: Yes No Holidays: Yes No
Do you have a car?	Yes No	Other method of transportation:
		What time/distance are you willing to travel?

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Professional References
Name:		Title:
Address:
Home Phone:		Work Phone:

Name:		Title:
Address:
Home Phone:		Work Phone:

Name:		Title:
Address:
Home Phone:		Work Phone:

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Additional Information
Do you have the legal right and necessary papers to work in the US? Identity and employment eligibility of all new hires will be verified as required by the Immigration Reform/ Control Act of 1986.	Yes No

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Attached Resume

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Acknowledgement
I certify that all statements in this application are true and correct to the best of my knowledge. I understand that any misrepresentation, false statements or omissions, that I have made throughout the application process, are considered sufficient cause for employment rejection as well as dismissal, no matter when discovered by DirectMed Health Services, Inc. I hereby release any persons involved in the investigation and or verification of my statements and background from any and all liability of whatever kind and nature.	Yes, I agree