HR Credentialing Packet

HR CREDENTIALING PACKET

Complete every section fully. All information supplied will be used to verify identity, employment history, professional credentials, and suitability for employment. Providing false, misleading, or omitted information may result in withdrawal of any employment offer or termination of employment.

Personal Information

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

Primary Phone:    Secondary Phone:

Position Information

Reporting Manager:    Proposed Start Date:

Full-time    Part-time    Per diem/PRN    Contract

Professional Licenses & Certifications

Primary License/Certification:    Number:

Issuing State:    Issue Date:    Expiration Date:

Education

Major / Field of Study:    Graduation Date:

Employment History (Most Recent First)

Employer 1

Job Title:    Supervisor:

Start Date:    End Date:

Employer 2

Job Title:    Supervisor:

Start Date:    End Date:

Professional References

Background Checks, Authorizations & Disclosures

By checking the box below, I authorize the organization, its agents, and third-party vendors to obtain consumer reports, criminal history records, employment verifications, education verifications, license verifications, and other investigative reports required to evaluate my application for employment. I understand that such checks may be conducted prior to hire and periodically during employment as permitted by law.

I authorize background and credential verification as described above.

Do you have any pending disciplinary actions, revocations, suspensions, or investigations related to any professional license or certification?    Yes    No

Have you ever been convicted of a felony or a crime involving moral turpitude?    Yes    No

Health, Immunization & Safety

TB Test Date (most recent):    TB Result:

Hepatitis B Series: Completed    Declined    Date of Declination or Completion:

Malpractice Insurance (if applicable)

Policy Number:    Effective Date:    Expiration Date:

Equal Opportunity & At-Will Employment

This organization is an equal opportunity employer and does not discriminate on the basis of race, color, religion, sex, national origin, age, disability, or any other classification protected by applicable law. By submitting this packet you acknowledge the organization's nondiscrimination policy.

Employment with this organization is at-will unless otherwise set forth in a written agreement signed by an authorized representative. At-will employment means either the employee or the organization may terminate the employment relationship at any time, with or without cause and with or without notice, to the extent permitted by law.

I acknowledge the Equal Opportunity policy.    I acknowledge the At-Will Employment statement.

Applicant Certification & Authorizations

I certify that all information in this credentialing packet is true, correct, and complete to the best of my knowledge. I understand that falsification, omission, or misrepresentation of information may be grounds for denial of employment or immediate termination if employed.

I authorize the release of information to the organization and its agents for purposes of verifying statements made in this packet, including but not limited to contacting prior employers, educational institutions, licensing boards, and professional references. I release from liability any person or entity providing information in good faith.

I understand that I may be required to submit to drug screening, background checks, and other pre-employment verifications; my continued employment may be conditioned upon satisfactory results of those checks.

I certify and authorize as stated above.

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