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Global Healthcare Group is an equal opportunity  employer. We comply with all applicable laws of the State of Pennsylvania and the Federal Government regarding employment practices. These statutes prohibit discrimination in employment based on race, color, sex, age, nationality, creed, and physical or mental disability.
Personal Information:-
Position Applied  For:
State Applied For
City Applied For:
First Name:
Last Name:
Current Address:
City/State/Zip  State Zip
Social Security#:
Home Phone:
Work Phone
Cell Phone
E-Mail Address:
General Information:
How did you find out about this job? 
Specify days & shifts willing to work: 
Are you available to work weekends?
Are you US citizen? Yes No.   If no, what type of visa you have:
Minimum acceptable salary: $ .  When can you begin to work?
Note: Verification of US citizenship or US employment authorization will be required within 3 business days of the commencement of employment
Professional Licenses:
State:      Number:      Expiry date:  
State:      Number:      Expiry date:

Education & Professional Licenses:-

School/College/University   With Location

Degree/Course

 Years Attended
From        To 

Other Courses/Certification:

 

Specialty:

Experience Classification

Number of Months Experience
 1.

 2.
 3. 
 4.
 5.
 6.
 7.

Employment History:
Please start with your most recent employer and list the last three jobs held.

(1) Employer: From To

Address:       Job Title
Duties Performed: Ph. No.

(2) Employer: From To

Address:       Job Title
Duties Performed: Ph. No.

Information provided in response to these questions will not necessarily bar employment. Answers to questions 1, 2, 4, 6 or 9 is “YES”, please give full details on separate sheet.

 
1. Has your clinical license to practice in any jurisdiction ever been limited, suspended or revoked?

Yes No 

2. Has your clinical privileges ever been suspended, diminished, revoked or not renewed?

Yes No

3.Do you have the ability to perform all essential job functions?

Yes No

4. Have you been convicted of a felony within the past five years? If so, state the offense and findings

Yes No

5. Have you ever applied for a position or been employed before at Global HealthCare Group?

Yes No

PLEASE READ CAREFULLY  

I certify that the statements made on this application are true and correct to the best of my knowledge and belief and hereby grant GLOBAL HEALTHCARE GROUP permission to verify such answers. I understand that any false statement on this application will be considered as sufficient cause for rejection of this application or for dismissal if such false statement is discovered subsequent to my employment. I authorize written access to any records concerning my education or employment background. I understand, that if, any inquiry is made, all information as to its nature and scope will be supplied upon written request. I will have to pass a post-employment physical examination, as a condition of employment. If this application is considered favorably, I agree to abide by and comply with all the employer’s rules. Your ability to complete this application clearly and effectively will be considered requirement for the job for which you are applying. As a policy of our agency, employees must have the ability to travel to clients throughout our service area. If traveling by automobile, current vehicle registration, automobile insurance and driver’s license must be on file.

Name of Applicant:

Date and Time:

Place:

 

                       

 
 
Copyright © Global Healthcare Group, division of Global Empire LLC. All Rights Reserved.
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