Respiratory Therapist Job Application I certify that the answers on this application are true and complete to the best of my knowledge. If this application leads to employment, I understand that the falsification of statements and/or misleading information may be considered a cause for dismissal. I understand that as part of normal employment procedures, a routine inquiry will be conducted and I authorize such investigation. * Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Date of birth * Driver's license number * RT license number * Has your RT license ever been suspended or revoked? * Yes No If yes, briefly explain. How did you hear about NPH? * Were you referred to us by a current NPH employee? If so, please list their full name below. Have you worked for NPH in the past? * Yes No If so, briefly explain your past work experience. Employment desired * Full-time Part-time Per-Diem Desired hours? * AM PM NOC Are you 18 or older? * Yes No Have you ever been convicted of a felony? * Yes No I certify that I am a U.S. citizen, permanent resident, or a foreign national with authorization to work in the United States. * Yes No By filling out this application, I give consent to release any information to Nurses and Professional Healthcare (NPH) pertaining to my employment. I also authorize NPH to disclose my references to any of its client institutions or affiliates. I voluntarily and knowingly authorize NPH to contact the following employers listed below to give records or information they may have concerning my present or prior employment (including character, earnings, history and reason for termination) and any other information requested by NPH to determine my eligibility for employment. * Name of Employer * Position held * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Start Date * End Date * Reason for leaving? * May we contact this employer? * Yes No No, still employed. Name of Employer * Position held * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Start Date * End Date * Reason for leaving? * May we contact this employer? * Yes No No, still employed. Name of Employer * Position held * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Start Date * End Date * Reason for leaving? * May we contact this employer? * Yes No No, still employed. Professional Reference #1 * First Name Last Name Phone * (###) ### #### Relationship * Professional Reference #2 * First Name Last Name Phone * (###) ### #### Relationship * Professional Reference #3 * First Name Last Name Phone * (###) ### #### Relationship * I understand that Nurses and Professional Healthcare is an Equal Opportunity Employer that ensures all employees are given equal and ample opportunity work. NPH is committed to recruiting, hiring and promoting our employees solely on the basis of merit and qualification without regard to a person’s age, alienage, color, marital status, national origin, disability, race, religion, sex, sexual preference or status as a disabled veteran. Equal opportunity and mutual respect are integral parts of Nurses and Professional Healthcare’s values. * Thank you for submitting your application to Nurses and Professional Healthcare. Your application is under review and we will be in touch soon. Gratefully,Team NPH
