HR Credentialing Application

HR Credentialing Application

Personal Information

Date of Birth:    Social Security Number (last 4):

Position Information

Desired Start Date:    Salary Expectations: $

Full-time    Part-time    Contract    Temporary

Licenses and Certifications

Professional License/Certification 1 — Type:   Number:

Issuing Authority:   Issue Date:   Expiration Date:

Professional License/Certification 2 — Type:   Number:

Issuing Authority:   Issue Date:   Expiration Date:

Employment History (most recent first)

Education

Field of Study:    Graduation Date:

References

Reference 1 — Name:    Phone:

Email:    Relationship:

Reference 2 — Name:    Phone:

Email:    Relationship:

Reference 3 — Name:    Phone:

Email:    Relationship:

Legal Disclosures and Declarations

At-Will Employment Statement: I acknowledge that, unless otherwise agreed in a written employment agreement signed by an authorized representative of the employer, my employment relationship, if any, is at-will. Either I or the employer may terminate the employment relationship at any time, with or without cause or notice.

Equal Opportunity: The employer provides equal employment opportunity to all applicants and employees without regard to race, color, religion, sex, national origin, age, disability, or other protected characteristics. All hiring decisions are based on job-related criteria.

Have you ever been convicted of a felony or pled guilty/no contest to a felony?   No    Yes

Have you ever had a professional license or certification revoked, suspended, or subject to disciplinary action?   No    Yes

Have you had any malpractice claims, settlements, or judgments against you?   No    Yes

Authorization and Release

I authorize the employer and its agents to contact my prior employers, educational institutions, references and any licensing authorities to verify the information provided herein. I authorize those persons and entities to release to the employer any records or information requested in connection with this application, including employment, disciplinary, licensing, education, and credentialing records.

I consent to the employer obtaining consumer reports, criminal background checks, and verification of professional credentials, and understand that continued employment, if any, may be conditioned upon satisfactory results of such checks.

Consent to Background and Reference Checks: I hereby grant consent

Applicant Certification

I certify that the information provided in this application and all attachments is true, complete, and correct to the best of my knowledge. I understand that false statements, omissions, or misrepresentations may result in denial of credentialing, withdrawal of an offer, or immediate termination if discovered after hire. I agree to notify the employer promptly of any changes to the information contained in this application.

I authorize verification of all statements and release the employer and its representatives from liability arising from such investigations. I understand that signing below constitutes my legal acknowledgement of the statements above.

Applicant Acknowledgement: I certify and agree

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