Employment Application

Apply right now on-line; it takes just a few minutes. Your application is the first step toward joining other first class health care professionals who are richly rewarded and professionally empowered.

Complete the application below and submit it to our recruitment staff. To include a resume with your on-line application, e-mail it to one of our recruiters.

Once your application is received, a member of our recruitment team will contact you. Our process is quick and designed for results! We have hundreds of positions in a variety of disciplines and specialties updated weekly.

Feel free to browse our latest offering of available jobs on our Employment Opportunities page or pick up the phone and give us a call.

* Indicates required field.

Name

*First Name

*Last Name	Middile Initial

*E-mail

*Professional discipline

Specialty	Date Available

*Recruiter Name (If not applicable please type "none")

Location desired

Job Number

Current Address (if other than permanent)

Street Address

City	State	ZIP

Home Phone		How late

Country

Work Phone

Cell Phone

Pager

Permanent Address

*Street Address

*City	*State	*ZIP

*Phone		Best time to call

Licensure

State	Expiration Date

State	Expiration Date

State	Expiration Date

Check One: Certified Registered Registry Eligible Other:
Certificate: Registration/Registration Number		Expiration Date

*Has your professional license or certification ever been investigated or suspended?
Yes No
If yes, please give details and current status:

*Have you ever been convicted of a crime other than a minor traffic violation?
Yes No
If yes, please give details and current status:

Have you ever been named as a defendant in a professional liability action?
Yes No
*Can you submit verification of your legal right to work in the U.S.?
Yes No
If you will be employed on a visa, please specify type of work visa:

Education

College Name	City, State

Diplomas/Degrees	Graduation Date

College Name	City, State

Diplomas/Degrees	Graduation Date

Employment History

Please indicate all of your employment for the past ten (10) years, beginning with your most recent employer. Please list each facility in which you have worked.
Are you employed now? Yes No
If so, may we contact your present employer? Yes No

Other names under which you have been employed:

First Facility/Employer
Facility/Employer	Department

Street Address

City	State	ZIP

Dates employed:	Reason for leaving:
from to
Position Held	Specialty

Supervisor's Name and Title	Phone

Staff? Yes No
Travel assignment? Yes No
Local staff agency? Yes No

Second Facility/Employer
Facility/Employer	Department

Street Address

City	State	ZIP

Dates employed:	Reason for leaving:
from to
Position Held	Specialty

Supervisor's Name and Title	Phone

Travel assignment? Yes No
Local staff agency? Yes No

Third Facility/Employer
Facility/Employer	Department

Street Address

City	State	ZIP

Dates employed:	Reason for leaving:
from to
Position Held	Specialty

Supervisor's Name and Title	Phone

Travel assignment? Yes No
Local staff agency? Yes No

Fourth Facility/Employer
Facility/Employer	Department

Street Address

City	State	ZIP

Dates employed:	Reason for leaving:
from to
Position Held	Specialty

Supervisor's Name and Title	Phone

Travel assignment? Yes No
Local staff agency? Yes No

Fifth Facility/Employer
Facility/Employer	Department

Street Address

City	State	ZIP

Dates employed:	Reason for leaving:
from to
Position Held	Specialty

Supervisor's Name and Title	Phone

Travel assignment? Yes No
Local staff agency? Yes No

Sixth Facility/Employer
Facility/Employer	Department

Street Address

City	State	ZIP

Dates employed:	Reason for leaving:
from to
Position Held	Specialty

Supervisor's Name and Title	Phone

Travel assignment? Yes No
Local staff agency? Yes No

Seventh Facility/Employer
Facility/Employer	Department

Street Address

City	State	ZIP

Dates employed:	Reason for leaving:
from to
Position Held	Specialty

Supervisor's Name and Title	Phone

Travel assignment? Yes No
Local staff agency? Yes No

Additional Work Experience / Comments

The information provided in the application for participation in the program is true, correct and complete. I acknowledge that any misstatement or omission of fact on the application may result in my disqualification from participation in the program. I authorize release of this application and reference information to client institutions, only after receiving my express written or verbal consent for each assignment opportunity. I understand that by giving permission to submit my application for assignment opportunities, I am also agreeing to any criminal background investigation that may be required by certain states or client institutions.

Date

Click the Submit button only once.
It takes a few seconds for the form to be submitted.
After submission you will receive online confirmation.

Richards Healthcare, Inc. is an equal opportunity employer.