MATRIX HEALTHCARE SERVICES, INC.
EMPLOYMENT APPLICATION


Applicant Name
E - Mail Address
SSN

Matrix Healthcare is an Equal Opportunity Employer by Choice

Application Date
Date Available to Begin
How Did You Hear About Us?
Other
If a Friend Referred You, Please State Their Name
Permanent Address
Street City State Zip
Current Address
Street City State Zip
Phone Information
Phone Number
Alternate Phone
Pager
Cell

 

Person to Notify in Case of Emergency
Name
Phone
Address


Licensure: LVN RN LPN
State of Licensure
License #
Date of Expiration
State of Licensure
License #
Date of Expiration
State of Licensure
License #
Date of Expiration

 

 


Educational Background
EDUCATION
NAME AND LOCATION OF SCHOOL
MONTH / YEAR GRADUATED
DIPLOMAS DEGREES
COLLEGE
GRADUATE SCHOOL
OTHER SCHOOL

 

 

 

 

 

 


Other Information
Nursing Specialty
Primary
Secondary
Shift Preference
Other       
Geographic Preference
Primary
Secondary

 

Certification
ACLS
TNCC
CCRN
CEN
CPR
NRP
PALS
Expiration Date

Immunization
PPD/ X Ray
MMR*
TETANUS
HEP - A
VARICELLA*
HEP - B*
BCIG
Date
Results / Titer
N/A
N/A
N/A
Verification required for assignment.       *Titer test required if immunization series is complete


Have you ever been investigated by federal or state authorities for an alleged violation of health care laws?
YES
NO
If yes please give detailed explanation on a separate page.
Have you ever been excluded from participation in a federal health care program ( ie. Medicare / Medicaid )?
YES
NO
If yes please give detailed explanation on a separate page.
Has any license / certification held by you ever been subject to disciplinary action, suspension or revocation?
YES
NO
If yes please give detailed explanation on a separate page.
Have you ever been convicted of a felony or misdemeanor?
YES
NO
If yes please give detailed explanation on a separate page.
Are you bilingual?
YES
NO
  
Language(s)

Please give any information you feel is important.

 

Employment History / References

History / Reference 1  
Travel Assignment:
Yes
No
 
Teaching Hospital:
Yes
No
Organization
Phone
Address
Dates of Employment
From
To
Position Held
Unit Type/Size
Supervisor
Reason for Leaving

History / Reference 2  
Travel Assignment:
Yes
No
Teaching Hospital:
Yes
No
Organization
Phone
Address
Dates of Employment
From
To
Position Held
Unit Type/Size
Supervisor
Reason for Leaving

History / Reference 3  
Travel Assignment:
Yes
No
Teaching Hospital:
Yes
No
Organization
Phone
Address
Dates of Employment
From
To
Position Held
Unit Type/Size
Supervisor
Reason for Leaving

History / Reference 4  
Travel Assignment:
Yes
No
Teaching Hospital:
Yes
No
Organization
Phone
Address
Dates of Employment
From
To
Position Held
Unit Type/Size
Supervisor
Reason for Leaving

History / Reference 5  
Travel Assignment:
Yes
No
Teaching Hospital:
Yes
No
Organization
Phone
Address
Dates of Employment
From
To
Position Held
Unit Type/Size
Supervisor
Reason for Leaving



Personal References:
Below please list the names of three persons not related to you, whom you have known at least one year that we may contact by phone
or mail. These individuals will serve as personal references for you. If phone contact only please list a convenient time for us to call them.
NAME
ADDRESS AND PHONE
Business
Years Known
   
 
 
   
 
 
   
 

 

I hereby authorize any investigator or duly accredited representative of Matrix Healthcare Services, Inc. bearing this release to obtain any information from schools, residential management agents, employers, criminal justice agencies, or individuals, relating to my activities. This information may include, but is not limited to, medical, academic, residential, achievement, performance, attendance, personal history, disciplinary, arrest, and conviction records. I hereby direct you to release such information upon request of the bearer. I understand that the information released is for official use by Matrix Healthcare Services, Inc. and may be disclosed to such third parties as necessary in the fulfillment of official responsibilities and facility contract obligations.

I hereby release any individual, including record custodians, from any and all liability for damages of whatever kind or nature, which may at any time result upon me on account of compliance, or any attempts to comply, with this authorization.

I understand that any negative information regarding my history may be grounds for Matrix Healthcare Services, Inc. to deny placement at client facilities.

I certify that the answers given by me to the foregoing questions and statements are all true and correct to the best of my knowledge. I agree that the company shall not be liable in any respect if my employment is terminated because of false statements or answers or misleading omissions made by me in this application. I also authorize the companies, schools, or persons named above to give any information they may have regarding me, whether or not it is in their records. I hereby release said companies, schools, or persons from all liability for any damages for issuing this information. I understand that this employment application and any company handbooks I may receive do not constitute contracts of employment or benefits.

I agree with the terms, stated above, concerning the Matrix Employment Application I have completed.  

Signature       Date