| Online Application


Delta Healthcare Providers
Employment Application

 

General Information

First Name:    
Last Name:    
Middle Name:  
Other Names Used:  
Home Phone:    
Work Phone:  
Mobile Phone:  
Social Security Number:  
Email Address:  
Best Time To Contact:  
Discipline:    
Secondary Discipline:  
Specialty:  
Secondary Specialty:  
Years of Experience:  
Ever worked as a Traveler?:  
Date Available  (mm / dd / yyyy):  


Contact Information

Current Street Address:    
Current City:    
Current State:    
Current Zip Code:    
Current Country:    
check if permanent address is same as current address
Permanent Street Address:  
Permanent City:  
Permanent State:  
Permanent Zip Code:  
Permanent Country:  


Emergency Contact Information

Name of Contact:    
Relationship:    
Phone:    
Street Address:  
City:  
State:  
Zip Code:  
Country:  


Education


University / College:    
City:    
State:    
Country:    
Graduation Date  (mm / yyyy):    
Degree Awarded:    


Licenses / Certifications (please list all active and inactive licenses)


 
License Type:    
License Number:    
State:    
Expiration Date  (mm / dd / yyyy):    
Restrictions:  


Employment History (please list last 10 years of employment history)


Facility Name:    
City:    
State:    
Zip Code:    
Current Employer ?  
May We Contact Employer ?  
Start Date  (mm / dd / yyyy):    
End Date  (mm / dd / yyyy):    
Reason For Leaving:    
Position Held:    
Discipline:  
Specialty:    
Other Specialty:  
Other Specialty:  
Travel Assignment ?  
Travel Company Name:    
Job Responsibilities:  


Disclosure Questions

Are you a U.S. Citizen or can you verify your legal right to work in the U.S.?
 

Has your license or certification ever been investigated or suspended?
 

Have you ever received a reprimand or been fined by any state licensing board?
 

Were you ever placed on probation, disciplined, formally reprimanded, suspended or asked to resign during an internship, residency, fellowship, preceptorship or other clinical education program?
 

Have you ever been disciplined by a federal or state governmental health program (ie: Medicare or Medicaid)?
 

Have you ever failed your national certification exam?
 

Do you have any reason to believe that you would pose a risk to the safety or well-being of your patients?
 

Has your name ever been listed on any sexual offender registry (federal or state)?
 

Release of Information

I understand that this application is for employment with Delta Healthcare Providers, LLC or Delta Flex Partners, LLC, both represented below as "The Company". I attest that I am the applicant and the information provided in this application is complete and accurate, to the best of my knowledge. Providing incomplete or inaccurate information may result in disqualification from the program, and may be a violation of state law(s) that could result in civil penalties. The Company is authorized to obtain information from my current and previous employers, and to release information in support of my application (application, references, background search results, etc.) to the Company's client institutions. The Company may also share information regarding my employment with its affiliates and appropriate governmental or licensing entities. I consent to receiving employment opportunity-related information at all phone numbers or email addresses that I provide. By submitting this application, I am also agreeing not to disclose information about opportunities presented to me by the Company to other staffing agencies and to notify the Company immediately if I accept a position with a client or affiliate of client within one year after presentation to client by the Company. I understand that the Company, certain states and/or Client institutions may require criminal background checks, and I consent to such checks. Prior to conducting any background checks that qualify as consumer or investigative consumer reports, I will be provided, and will return, separate disclosure and acknowledgement forms as required by the Company.

I agree with the statements above:  
Date: