First Name   Last Name   Date

Address   Apt/Unit   City/State/Zip

Home Ph#   Cell#   Email

Job Class    Specialty/Unit   Shift Pref 7a-3p 3p-11p 11p-7a 7p-7a 7a-7p

Type of work Per Diem Permanent Placement Temp-Perm Placement        Desired# hours per week

Type of license/cert State AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Number                                                                     Type of license/cert State AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Number

Do you have CPR/BLS ACLS PALS IV Cert  Other                                                                                                                              If you have others, please list

Have you ever been convicted of a crime or pled guilty to any criminal charges? Yes No                                                                                       If yes, please explain

Have you ever been investigated for a suspected violation of any laws? Yes No                                                                                                        If yes, please explain

Have you ever been involved in a malpractice claim or suit? Yes No                                                                                                                          If yes, please explain

I hereby certify that the information provided is true and accurate to the best of my knowledge. I authorize AHSS to investigate and verify this information. If any statements are found to be false on this application or anytime during the hiring process, I understand I will no longer be eligible for employment with AHSS.

I understand that completing this application or any other documents provided to me during the hiring process, is not intended to be an employment contract.

I understand this information is considered confidential and will be treated appropriately. All prospective applicants will receive consideration without discrimination because of sex, race, age, creed, religion, national origin, or handicap.

I have read and understand the above statements