Apply for Dialysis - Licensed Practical Nurse

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Summary
Title:Dialysis - Licensed Practical Nurse
ID:1616
Location:Greenville, MS
Department:DIALYSIS
Job Type:PRN
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Application Information
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Application for Employment Delta Health
PERSONAL INFORMATION
Yes   No
Yes   No
Yes   No
Yes   No
* Have you ever been convicted of a crime or violation other than a minor traffic infraction?:
Yes   No
If yes, when, where, nature of offense (No one will be automatically disqualified from consideration based on criminal history.):
* Are you currently excluded as a provider of services by Medicare, Medicaid or any other federal or state health care program?:
Yes   No
EMPLOYMENT DESIRED
Full Time   Part Time   Seasonal
Yes   No
Yes   No
PROFESSIONAL LICENSES/CERTIFICATIONS
Type State Issued
and Address		 Year of Graduation Expiration Date Number

EDUCATION

Give record of all High Schools, Colleges, Universities and Vocational/Technical Schools you have attended.

School 1

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School 2

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School 3

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School 4

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School 5

Yes   No
EMPLOYMENT HISTORY

Give your full employment record, starting with your current or most recent employment. At least 1 employer is required to complete the application

Employer 1

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*
*
*
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*
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Employer 2

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Employer 3

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Employer 4

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Employer 5

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REFERENCES

Please provide three references (not relatives). At least 2 references are required to complete this application.

Reference 1

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*
*
*

Reference 2

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*
*

Reference 3
AUTHORIZATION

I hereby certify that all of my statements and information are true, and I understand that any false statements or omissions are cause for termination. I agree to submit to a drug/alcohol test and/or physical following any conditional offer of employment, and I grant permission to Delta Health System - The Medical Center to investigate my criminal history, education, prior employment history and references, and hereby release all persons or agencies from all liability for any damage for issuing this information.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of "at will" nature, which means that I, the employee, may resign at any time, and the employer may discharge me, the employee, at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed except in writing by the Chief Executive Officer or Chief Human Resources Officer.

I understand that this application is current for only THREE MONTHS. At the end of that time, if I do not hear from Delta Health System - The Medical Center and still wish to be considered for employment, it will be necessary for me to update my application.




I agree that this form may be electronically signed and agree that my typed signature is the same as a handwritten signature for the purposes of validity, enforceability, and admissibility.
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