<%@LANGUAGE="VBSCRIPT" CODEPAGE="CP_ACP"%> KTCusa-Employment Application Form, Nursing jobs in Detroit, RN jobs in detroit
    
KTC Health Care, Inc.
EMPLOYMENT APPLICATION
It is the policy of KTC Health Care, Inc. to provide equal employment opportunities to all applicants and employees without regard to any legally protected status such as race, color, religion, gender, national origin, age, disability or veteran status.
PERSONAL INFORMATION      

Applicant Name:
       
Last First MI
  Address:                    
City      
State      
  Zip      
  Phone      
 
Cellular Phone/Pager
        
  E-mail        
Social Security Number
Driver's Licence Number
What State issued your Licence?
How will you get to work?                
Are you at least 18 years old?     Yes No                          
Are you legally eligible for employment in the United States?    
Yes
No          
Have you ever been convicted of a felony?
Yes
No                            
    If yes, please describe:
THE EXISTENCE OF A CRIMINAL RECORD DOES NOT CONSTITUTE AN AUTOMATIC BAR TO EMPLOYMENT UNLESS RELEVANT TO THE TYPE OF EMPLOYMENT.
Have you applied to our company previously?
Yes
No
If yes, When?
How were you referred to KTC?
Who should be contacted if you are involved in an emergency?        
Contact Name Relation            
Day Time Phone Evening Phone
EMPLOYMENT DESIRED:
Job Position Applied For:              
Are you physically able to perform the essential functions of the position without special accommodation?
Yes
No
   
What special accommodation, if any, would you require?
How many hours per week you are willing to work?
Are you willing to work any shift, including nights and weekends?
Yes
No
        
If no, please state any limitations:
What is the maximum number of miles you are willing to travel to an assignment?
If you are offered employment, when would you be available to begin work?
EMPLOYMENT HISTORY:
(List your current or most recent employment first.)
1.Employer Name      
Address
City
State
Zip
Phone Number
Position title
Unit/Floor  
Dates Employed    
From
To
  
Supervisor  
Reason for leaving:      
 
2.Employer Name          
Address
City
State
Zip
Phone Number
Position title
Unit/Floor            
Dates Employed    
From
To
  
Supervisor            
Reason for leaving:          
 
3.Employer Name          
Address
City
State
Zip
Phone Number
Position title
Unit/Floor          
Dates Employed    
From
To
  
Supervisor          
Reason for leaving:        
Education and Training: (List your education and training.)
High School Name   Address
9
10
11
12
Diploma
Yes
No
Last Grade Completed?
College Name   Address        
Did you receive a degree? Yes No       If yes,Degree received?:    
Other Training (graduate, technical, vocational):    
Awards, Honors, Special Achievements:
Do you have a current BLS-C card? Yes No   If yes, date of expiration:    
Do you have a current ACLS card? Yes No If yes, date of expiration:
Do you have a current PALS card? Yes   No If yes, date of expiration:  
Do you have a current NRP card? Yes No If yes, date of expiration:
 
AREAS OF SPECIALITY
Please enter the number of years of experience for each area of practice for which you have current experience.
Speciality Years of Experience
RN Medical/Surgical
RN ICU
RN Emergency Room
RN Telemetry
RN Other (please specify)
CENA Nursing Home
CENA Hospital
CENA Other (please specify)
LPN Medical/Surgical
LPN ICU
LPN Emergency Room
LPN Telemetry
LPN Other (please specify)
CRNA:
Surgical Tech:
X-Ray Tech:
Respiratory Therapist
Other Discipline/Specialty (please specify)
 
   
Professional References:
List two people whom you have known for at least 3 years that would be willing to provide reference for you. (Please exclude family.)
Name
Address
City
State
Zip
Telephone
Relation
 
Name
Address
City
State
Zip
Telephone
Relation
 
   
CERTIFICATION

I certify that the information provided on this Application is truthful and accurate. I understand that providing false or misleading information will be the basis for rejection of my Application, or if employment commences, immediate termination.

I authorize KTC Health Care, Inc. to contact former employers and other organizations regarding my employment, education, credit history and criminal background. I authorize all organizations to fully and freely communicate information regarding my previous employment, attendance, grades, credit worthiness and criminal history. I authorize those persons designated as references to fully and freely communicate information regarding my previous employment and education.

If an employment relationship is created, I understand that unless I am offered a specific written contract of employment signed on behalf of the organization by its Principal, the employment relationship will be entirely "At Will". In other words, with appropriate notice, I will have the full and complete discretion to end the employment relationship when I choose and for reasons of my choice. Similarly, my employer shall have the same right. Moreover, no agent, representative, or employee of KTC Health Care, Inc. except in a specific written contract of employment signed on behalf of the organization by its Principal, has the power to alter or vary the "At Will" nature of the employment relationship.

I HAVE CAREFULLY READ THE ABOVE CERTIFICATION AND I UNDERSTAND AND AGREE TO ITS TERMS.