HR Credentialing Document

HR Credentialing Document

Personal Information

Position Information

Licenses and Certifications

List current professional licenses, certifications, registrations or credentials. Attach copies of all relevant documents upon submission.

Education

Employment History (most recent first)

Employer 1

Employer 2

Professional References

Provide three professional references who can verify your qualifications and work history.

Background and Disclosures

Please answer the following questions. A positive response requires a full explanation in the space provided and documentation where applicable. Disclosure will not necessarily disqualify candidacy but failure to disclose may.

Have you ever been convicted of a felony or misdemeanor related to the duties of the position?

Have you ever been subject to professional disciplinary action, license suspension, revocation, or restriction?

Have you ever had a malpractice claim or professional liability claim filed against you?

Legal Notices, Authorizations and Certifications

At-Will Employment: I understand and acknowledge that if employed, my employment is at-will and may be terminated by either party at any time, with or without cause, unless a separate written agreement signed by a duly authorized representative provides otherwise.

Equal Opportunity: I acknowledge that this organization is an equal opportunity employer. Decisions are made without regard to unlawful considerations and in accordance with applicable law.

Authorization to Verify: I authorize the organization, its agents, and credentialing representatives to verify all statements in this document, to contact prior employers, educational institutions, licensing boards, references, and to obtain criminal, professional discipline, and employment history records. I release such persons and organizations from liability for furnishing such information to the extent permitted by law.

Background Checks and Drug Testing: I consent to pre-placement and periodic background checks, including criminal history checks, and drug and alcohol testing where applicable as a condition of credentialing and continued participation in the workforce. I understand that refusal to consent may disqualify me from credentialing consideration.

Applicant Certification

I certify under penalty of perjury that the information contained in this HR Credentialing Document and any attachments is true, complete and correct to the best of my knowledge. I understand that materially false statements, omissions, or misrepresentations may disqualify me from credentialing or may be grounds for disciplinary action or termination if employed.

I further certify that I will promptly notify the organization in writing of any changes to the information provided herein, including changes in licensure status or any new professional actions that occur after submission and prior to credentialing decision.

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