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Create ITN Employment Application

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Step 1 of 8 Applicant Information

I understand that if I am offered employment, I will be required to submit proof of U.S. citizenship or immigration documentation establishing authorization to work in the United States.
Date Residence Began
E.g., May 2012
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Step 2 of 8 Contact Information

No Spaces
Current Address
 
 
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Step 3 of 8 Education

Order
School / Training
School Address
 
 
Attended From
E.g., 05/2012
Attended To
E.g., 05/2012
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Step 4 of 8 Licenses / Certifications

Order
License / Certification
Expiration Date
E.g., 05/20/2012
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Step 5 of 8 Experience: Work History

Order
Employer
Date Employment Began
E.g., 05/2012
Date Employment Ended
E.g., 05/2012
$
$
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Step 6 of 8 Experience: Skills

Skill Set

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Step 7 of 8 Other History

Within the past 5 years, were you separated from military service under conditions other than honorable?
  1. Controlled substance-related offense in the three-year period immediately preceding the date of the application.
  2. State or federal healthcare program-related crimes.
  3. Patient abuse, neglect or mistreatment.
  4. Felony conviction after August 21, 1996 of fraud, theft, embezzlement, breach or fiduciary responsibility or other financial misconduct in connection with a healthcare program.
  5. Felony conviction after August 21, 1996 relating to the unlawful manufacture, distribution, prescription, or dispensing of a controlled substance.
  6. Any act, attempt, or conspiracy to overthrow the State or the federal government by force or violence.
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Step 8 of 8 Certification Agreement

  1. I certify that all statements made on this application for employment are true and complete to the best of my knowledge. I understand and agree that any misrepresentation or omission whenever discovered is grounds for the denial of or immediate separation from employment.
  2. If employed by Island Temporary Nursing (ITN), I agree to conform to the guidelines and policies of ITN. I understand that unless otherwise provided by collective bargaining agreements or law, and if appointed to an exempt position, my exempt employment is “at will” and may be terminated by myself or by ITN with or without cause.
  3. I consent to and authorize ITN to communicate with all my former employers, school officials, government agencies, and persons named as references, and to make any investigation of my employment history. In consideration for ITN's review of this application, I release ITN and any other person or company responding to any reference or information from any claim or liability regarding any information or opinion supplied. I understand that any offer of employment is subject to satisfactory references. In consideration for employment, I further authorize ITN to disclose information about my job performance with ITN to any prospective employer upon request of that prospective employer. I specifically waive any claims against ITN for such disclosure unless it is established by clear and convincing evidence that such information was knowingly false or rendered with malicious purpose and also such disclosure was not otherwise privileged.
  4. I understand that other checks required by ITN to comply with various governmental programs such as Medicare and Medicaid will be conducted and any offer of employment and continued employment will be contingent on the satisfactory return of these checks.
  5. State and Federal criminal history record checks will be conducted. An applicant with a conviction may be denied employment.
  6. Conditions for business purposes include, but are not limited to the following: overtime, shift work, rotating shift work schedule, or a work schedule other than the weekdays. I understand and accept these as conditions of my employment.
  7. I understand and agree that if I am employed by ITN, all of the foregoing terms are continuing conditions of my employment with Island Temporary Nursing.

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