Clinical Practice Partners - EMPLOYMENT APPLICATION

First Name*

Last Name*

Email Address*

Phone Number*

Current Address*

City*

State*

Zip Code*

Position Applying For*

Nurse Practitioner (NP)

Registered Nurse (RN)

Licensed Practical Nurse (LPN)

Medical Assistant (MA)

Certified Nursing Assistant (CNA)

Phlebotomist

Preferred Work Type*

Full-Time

Part-Time

Per Diem

Contract

Desired Pay Rate*

Available Start Date*

Availability*

Weekdays

Weekends

Nights

Holidays

On-Call

Maximum Hours Per Week*

10–20

20–30

30–40

40+

Are you legally authorized to work in the U.S.?*

Yes

No

Will you require sponsorship now or in the future?*

Yes

No

Have you ever worked for this company before?*

Yes

No

Do you currently hold a valid professional license?*

Yes

No

License Type:

License Number:

State Issued:

Expiration Date:

Certifications:

BLS

ACLS

CPR

PALS

Other

Employer Name

Position Held

Duration of Service

Supervisor Name and Contact Number

Reason for Leaving

Key Responsibilities

Highest Level of Education

School Name

Field of Study

Graduation Year

Clinical Skills

Patient Care

IV Therapy

Phlebotomy

EHR Systems

Medication Administration

Software Experience

Additional Skills

Have you ever been convicted of a felony?*

Yes

No

Have you ever had a professional license suspended or revoked?*

Yes

No

Are you able to pass a background check and drug screening?*

Yes

No

If YES to any, please explain

1. Reference Name*

1. Relationship*

1. Phone Number*

1. Email*

2. Reference Name*

2. Relationship*

2. Phone Number

2. Email

Emergency Name, Relationship and Contact Number

Date today:

Acknowledgment Statement

Acknowledgment Statement- Review & Sign

Acknowledgment Statement

"I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that false or misleading information may result in disqualification or termination. I authorize Clinical Practice Partners to verify my credentials, employment history, and conduct background checks as required."

EMPLOYMENT APPLICATION

SECTION 1: PERSONAL INFORMATION

SECTION 2: POSITION INFORMATION

SECTION 3: AVAILABILITY

SECTION 4: WORK ELIGIBILITY

SECTION 5: LICENSES & CERTIFICATIONS

SECTION 6: EMPLOYMENT HISTORY

SECTION 7: EDUCATION

SECTION 8: SKILLS & COMPETENCIES

SECTION 9: BACKGROUND & DISCLOSURE

SECTION 10: REFERENCES

SECTION 11: EMERGENCY CONTACT

SECTION 12: AGREEMENT & SIGNATURE

Acknowledgment Statement