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Trusted Nurse Staffing (TNS), is an equal employment opportunity employer. TNS considers all qualified applicants for employment, without regard to: race, sex (including pregnancy), color, religion, age, national origin, citizenship, physical or mental disability, sexual orientation Vietnam era veteran status, disabled veteran status, or any other category protected under applicable federal or state law.

Personal Information

Are you willing to travel?

If Yes, Where?
Education

Did you graduate

Did you graduate

Did you graduate

Did you graduate

References
Licensure/Certifications



1. Have you ever been convicted of a criminal felony or misdemeanor (except minor traffic offenses)?

If Yes, Please Explain?



2. Has your license ever been investigated, suspended or revoked?

If Yes, Please Explain?



3. Have there been or are there any current, pending investigations, incidents, claims, suits, settlements or arbitration proceedings involving alleged mal-practice relating to your clinical activities?

If Yes, Please Explain?



4. Has your professional liability insurance ever been denied or limited?

If Yes, Please Explain?



5. Have you ever been the subject of an investigation by any private or government agency concerning your participation in any Medicare or Medicaid program?

If Yes, Please Explain?



6. Have you ever been denied membership or renewal there of, or been subject to disciplinary action by any medical organization?

If Yes, Please Explain?



7. Have you ever been the subject of any other professional sanctions not documented above?

If Yes, Please Explain?



Employment History

Please list chronologically, beginning with most recent experience.









 



APPLICANT STATEMENT

I certify that answers given herein are true and complete to the best of my knowledge.  I understand that false or misleading information in my application or interview(s) may result in rejection of my application or, in the event of employment, discharge.


I authorize verification of all statements contained in this application for employment as may be necessary at arriving at an employment decision.  I release Trusted Nurse Staffing from any and all damage resulting from the verification process.


I consent to a pre-employment drug screen, and I acknowledge that at anytime the company may withdraw and revoke any offer of employment.  I also authorize Trusted Nurse Staffing to run a background investigational screening.

I authorize Trusted Nurse Staffing to release information contained in this application or obtained by Trusted Nurse Staffing pursuant to its credentials verification process to any affiliate, customer, payor or Contractor of Trusted Nurse Staffing.


I understand that, if hired, I am required to abide by all rules and regulations of Trusted Nurse Staffing.  I understand that I may be required to sign a confidentiality and/or business ethics agreement in connection with any employment with Trusted Nurse Staffing.


I understand that this application and any of Trusted Nurse Staffing’s employment policies or employment handbooks are not intended to be nor constitute a contract of employment.


I understand that if I become employed with Trusted Nurse Staffing, I will be an At-Will employee.  Accordingly, the employment relationship may be terminated, with or without cause, and with or without notice, at the option of either the company or me.  I further understand that no supervisor, manager or representative of the company has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the foregoing.