Online Nurse Job Application - Angel Healthcare Staffing

Nurse Staffing Company and Nurse Staffing Services - Angel Healthcare Staffing

Date Available for Work *
First Name *	Middle Initial	Last Name *
Current Address *
Current Address *	City * State * Zip *
Email Address *
Current Phone Number *		Other Phone Number	Cell Other
Social Security Number
Can you provide proof of eligibility to work in the United States? * Yes No
Emergency Contact		Phone Number
Emergency Contact	(not living with you)	Phone Number
Type of Degree *	RN LPN/LVN CNA Other (please specify below)	Shift Preference *	AM PM Either
How did you hear about Angel Healthcare?

EDUCATION
Name and Locations of School(s)	Graduated Date	Type of Degree
*	*	*

LICENSURE
(Please list all including expired)

Professional License/
Technical Certificate

# *

Which of these licenses is your original state of licensure? *

Has your license or certification ever been under investigation? * Yes No

If YES, please explain

Has your license or certification ever been revoked or under suspension? * Yes No

If YES, please explain

Resuscitation Credential	Expiration Date
ACLS
BLS
ENPC
NRP
PALS
TNCC

PROFESSIONAL CONTINUING EDUCATION
Course Name	Date	CEUs Earned

Have you ever been convicted of a felony that would prohibit your employment at a health care facility? *
Yes No

Have you ever been convicted of a felony in the past five years? * Yes No

Are you currently employed? * Yes No

Do you have any physical or mental conditions that would inhibit or restrict your ability to perform the essential functions of your job? * Yes No

If YES, what are they?

Do you have one year of acute care experience in the past two (2) years? * Yes No

PLEASE CHECK ALL THAT APPLY:
I would like to be considered for travel positions with Angel Healthcare Staffing
Travel Cities:

I would like to be considered for local positions with Angel Healthcare Staffing
City/Cities Desired Locations:

EMPLOYMENT EXPERIENCE

Begin with your current or last job.
Provide, in chronological order, your last four (4) employers.
Include any gaps of employment with a brief description.

Current/Last Employer *		Phone
Address
Address	City * State * Zip
Supervisor	May this person be contacted for a reference? Yes No
Job Title *		Specialty/Unit
Employment Dates	From * To *		Full Time Part Time
Supervisory Experience?	Yes No	Reason for Leaving *
Comment

Current/Last Employer		Phone
Address
Address	City State Zip
Supervisor	May this person be contacted for a reference? Yes No
Job Title		Specialty/Unit
Employment Dates	From To		Full Time Part Time
Supervisory Experience?	Yes No	Reason for Leaving
Comment

Current/Last Employer		Phone
Address
Address	City State Zip
Supervisor	May this person be contacted for a reference? Yes No
Job Title		Specialty/Unit
Employment Dates	From To		Full Time Part Time
Supervisory Experience?	Yes No	Reason for Leaving
Comment

Current/Last Employer		Phone
Address
Address	City State Zip
Supervisor	May this person be contacted for a reference? Yes No
Job Title		Specialty/Unit
Employment Dates	From To		Full Time Part Time
Supervisory Experience?	Yes No	Reason for Leaving
Comment

PRIMARY APPLICANT AGREEMENT
Please be certain to read and sign the Primary Application Agreement.

The following agreement is for informational purposes. Angel Healthcare Staffing, has the right to decide to hire any applicant, and the applicant has the right to choose to be placed by Angel Healthcare. Both will agree to the following:

Angel Healthcare's COMMITMENT

PLACEMENT. Angel Healthcare Staffing, will attempt to secure placement of the Applicant on a per diem basis at an assignment with a facility. This time period may be extended at the completion of the assignment as long as the facility, applicant, and Angel Healthcare Staffing, agree on the terms agreed to at the time of the extension.

PAY RATE. Angel Healthcare Staffing, agrees to pay the applicant according to the pay rate indicated on the Employee Rate Sheet, and in accordance with applicable Federal, State, and Local laws. The pay rate may vary according to location of assignment and may change if there is an extension of the current assignment or relocation to a new assignment. Any pay rate changes will be addressed with an updated Employee Rate Sheet, which is provided to the applicant for acceptance. Rejection of the Employee Rate Sheet constitutes immediate termination of any arrangement between Angel Healthcare Staffing, and the Applicant.

24/7. Angel Healthcare Staffing's phone lines are open twenty-four (24) hours per day, seven (7) days a week for the Applicants convenience. Angel Healthcare Staffing, reserves the right to change hours of operation at anytime with or without notification.

DISCLAIMER. Angel Healthcare Staffing, reserves the right, and the Applicant acknowledges that Angel Healthcare Staffing, may at anytime and for any reason, change any rules, regulation, and/or policies, with or without notice.

APPLICANT'S COMMITMENT

EDUCATION AND TRAINING. Applicant states that he/she has obtained education and training in the healthcare field and is duly licensed and authorized to practice nursing.

PLACEMENT ACCEPTANCE. Once Corporation secures placement for Applicant at an assignment, Applicant agrees that his or her acceptance, will be binding. All placement details specific to assignments will be derived from the parameters outlined in the Nurse Profile that Applicant completes upon hire. Applicant is obligated to accept placement position secured by Corporation as outlined in the Nurse Profile. It is the responsibility of the Nurse to update his/her profile so that is it current at all times.

EMPLOYEE AT WILL. Applicant acknowledges that Angel Healthcare Staffing, employs Applicant “at will” and that no employment promises have been made for any duration of time. Specifically, Applicant understands that Applicant may quit employment at any time with Angel Healthcare Staffing, with or without notice. Similarly, Applicant understands that Angel Healthcare Staffing, may discharge Applicant at any time, without notice, for any lawful reason or no reason. Contracts of employment can only be made by a written agreement between Applicant and Angel Healthcare Staffing, and require the approval and signature of the President and Chief Executive Officer of Angel Healthcare Staffing, or authorized representative. Further, for whatever reason, should Facility decide to end Applicant’s assignment prior to completion date, Angel Healthcare Staffing, may propose a new assignment as long as Applicant is in good standing with Angel Healthcare Staffing,

NON-DISCLOSURE AND LIMITED NON-COMPETE. Applicant agrees not to disclose any of Angel Healthcare Staffing, trade secrets or any confidential or proprietary information of Angel Healthcare Staffing, Angel Healthcare Staffing, employees, Facilities, or of patients of Facilities. Applicant further agrees not to compete either as a direct competitor or with a competing company at the Facility assignment where Applicant has been placed by Angel Healthcare Staffing, for a term of three (3) months after Applicant’s final day of work at Facility.

NON-SOLICITATION OF CORPORATION EMPLOYEES. Applicant agrees not to solicit Angel Healthcare Staffing, employees to work for any competing company while on assignment with a Angel Healthcare Staffing, facility, and for a period of three (3) months thereafter.

DRUG SCREENS. Prior to placement and throughout employment with Angel Healthcare, Applicant consents to a urine, blood or breath sample for the purposes of an alcohol, drug, intoxicant, or substance abuse screening test. Applicant also gives permission for the release of the test results determining the fitness of employment or continued employment. Applicant will utilize clinics that are approved by Angel Healthcare Staffing,

BACKGROUND CHECKS. Before the Applicant is placed and throughout employment with Angel Healthcare, Angel Healthcare Staffing, may, upon a facility’s request, conduct background checks of any kind from any location for any purpose Angel Healthcare Staffing, considers reasonable. Applicant also gives permission for the release of the results for determining the fitness of employment or continued employment.

EMPLOYMENT AND MEDICAL INFORMATION RELEASE. I authorize Angel Healthcare Staffing, to release any and all confidential employment and medical information contained in my employment file to any medical facility or entity with whom Angel Healthcare Staffing, has a staffing agreement, and to any other governmental or regulatory agency at such agency’s request. For all other purposes, Angel Healthcare Staffing, shall keep my employment and medical records confidential and shall advise any medical facility or other entity to which records have been provided to also keep such records confidential. I hereby hold Angel Healthcare Staffing, harmless for any result(s) that arise with regards to the release of this confidential information by Angel Healthcare Staffing,

RECORDING OF TIME WORKED. Applicant agrees to abide by Angel Healthcare Staffing, procedures for reporting of time worked including hospital supervisor approval for shift time worked and missed lunch periods. The Angel Healthcare Staffing, workweek begins 7 AM Sunday and concludes at 6:59 AM Sunday. Applicant’s reporting of time worked must reach Angel Healthcare Staffing, each week by 12 PM Central Time each Monday to be paid in the current week. Any late submissions may be paid the following week.

LUNCH BREAK POLICY. Applicant will clock in and out for a period of no less than thirty (30) minutes and no longer than one (1) hour or per facility policy for meal periods. If the Facility requests the Applicant to work their lunch period due to patient care and safety, the Applicant agrees to obtain approval by Facility Nurse Manager as required by Angel Healthcare Staffing, for each applicable shift.

TERMINATION. Applicant understands that if he/she leaves his/her assignment early for any reason or is terminated by Angel Healthcare Staffing., Applicant is expected to vacate company premises and is expected to vacate company provided housing within 24 hours, and will be responsible for the return of all costs incurred by Angel Healthcare Staffing, for such termination. Applicant authorizes Angel Healthcare Staffing, to deduct any incurred costs from their paycheck.

GENERAL

CHOICE OF LAW. This agreement will be construed in all respects according to the laws of the state of Tennessee.

CONFIDENTIALITY OF AGREEMENT. Angel Healthcare Staffing, and Applicant will maintain the confidentiality and exclusivity of this Agreement.

AGREEMENT REVIEW. Angel Healthcare, and Applicant agree that each party has fully read and reviewed this Agreement and should any ambiguities arise, the interpretation of the ambiguity will not automatically be that of the Applicant.

EQUAL OPPORTUNITY EMPLOYER. Angel Healthcare Staffing, is an equal opportunity employer. Angel Healthcare Staffing, does not discriminate in respect to hiring, firing, compensation, and all other terms and conditions of privileges of employment on the basis of race, color, national origin, sex, age or related medical conditions, or disability.

NOTICES. Any notices, which are required or permitted will be in writing and will be, deemed properly delivered to the other party when sent U.S. Mail, certified, postage prepaid and addressed to the following:

Applicant understands that this is not a complete listing of Policies and Procedures of Angel Healthcare Staffing, Complete details are included in the Angel Healthcare Staffing, Policy and Procedures manual that will be given to the applicant upon hire.

For Corporation:

Angel Healthcare Staffing,
3225 Kirby Whitten Parkway
Suite 6
Bartlett, TN 38134

For Applicant:

Applicant Name:*
Applicant Address:*
Applicant Signature: ELECTRONIC SIGNATURE BELOW

NURSE ASSOCIATE PROFESSIONAL CONDUCT EXPECTATIONS

Your professional conduct and clinical performance on Angel Healthcare Staffing, assignments is directly related to our ability to solicit new and interesting job opportunities for you. Toward that end we expect that you will adhere to the following Professional Conduct Expectations while on assignment for Angel Healthcare Staffing, Failure to meet these expectations could lead to your termination from the company.

I will not discuss any elements of my compensation with anyone employed at the host facility.
I will not discuss any previous assignment worked for Angel Healthcare Staffing, with anyone employed at the host facility.
I will not recruit any nurses at the host facility, whether temporary or permanent employees.
I will communicate with the management, staff and patients of the host facility in a respectful manner at all times.
I will honor all terms of the primary applicant agreement.
I will honor the policies and procedures of Angel Healthcare Staffing, and the host facility.
I certify that I have read, understand and intend to comply with the Primary Applicant Agreement and Professional Conduct Expectations and that the facts contained in this application are true and accurate. I understand that any misrepresentation or omission of facts is cause for dismissal. I authorize the employer to investigate any and all statements contained herein and request the persons, firms, and/or corporations named above to answer any and all questions relating to this application. I release all parties from liability, including but not limited to, the employer and any person, firm or corporation who provides information concerning my prior education, employment or character.

PLEASE NOTE:
BEFORE SUBMITTING THIS APPLICATION, YOU MUST AGREE TO THE FOLLOWING TERMS AND CONDITIONS.

I attest that the information provided in this application is complete and accurate, to the best of my knowledge. Providing incomplete or inaccurate information may result in disqualification from possible employment with Angel Healthcare Staffing, and may be a violation of state law(s) that could result in civil penalties. Angel Healthcare Staffing, is authorized to obtain information from my current and previous employers, and to release information in support of my application (application, references, background search results, etc.) to client institutions and to appropriate governmental or licensing entities. Angel Healthcare Staffing, may also share applicant information with its affiliates. I understand that Angel Healthcare Staffing, certain states and/or client institutions may require criminal background checks, and I consent to such checks. Prior to conducting any background checks that qualify as consumer or investigative consumer reports, I will be provided and will return, separate disclosure and acknowledgement forms as required by Angel Healthcare Staffing.

Electronic Signature Statement: I agree that inserting my personal information above represents my signature.

Name of Applicant *

Signature of Applicant *
(type full name)

Signature Date *

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