Stonehouse Job Application Form

This application is designed for the use of individuals applying for various types of positions. Some questions may not be completely applicable to your situation, but we ask that you answer all job-related inquiries to the best of your ability. Stonehouse Medical Staffing considers all applicants for all positions without regard to race, color, creed, religion, national origin, sex, age, citizenship, veteran status, disability, or any other legally protected status. When completing this application, please exclude information that would indicate these or any other similarly protected status.

Position Applying For
PERSONAL INFORMATION
Name First Last
Phone - (###) - ### ####
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Social Security Number
Email *
EDUCATIONAL & LICENSING INFORMATION

Please complete the fields that are applicable to your level of education and leave the remaining fields blank. At the bottom the education/licensing section there is a field for any notes you'd like to share with us.
High School
High School GPA
High School Degree
Years of High School Completed
Did You Graduate High School?
College/Medical Facility
College/Medical Facility GPA
College/Medical Facility Degree
Years of College/Medical Facility Completed?
Did You Graduate College/Medical Facility?
Graduate School
Graduate School GPA
Graduate School Degree
Years of Graduate School Completed
Did You Graduate Graduate School?
Certification
Date Certification Completed
Certification Expiration Date
License Types, State, Number and Expiration Date

Please list all of your licenses, the state they are applicable to, the licenses number and the expiration date, one per line. Ex: License Type, State, Number, Expiration Date
Notes About Your Education Experience
EMPLOYMENT HISTORY

Please attach your resume to this application and complete this section in its entirety. Start with your current or most recent employment. We will assume we have your permission to contact these companies unless you indicate in writing to the contrary.
Upload Your Resume
Organization #1
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Duties
From/To
Supervisor
Phone - (###) - ### ####
Base Salary
Additional Compensation
Reason For Leaving
Organization #2
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Duties
From/To
Supervisor
Phone - (###) - ### ####
Base Salary
Additional Compensation
Reason For Leaving
PROFESSIONAL REFERENCES

Please list additional business references here if there are individuals, other than those listed in the employment history section, whom we can contact.
Reference #1 First Last
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Phone - (###) - ### ####
Email
How do you know this person?
Reference #2 First Last
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Phone - (###) - ### ####
Email
How do you know this person?
Reference #3 First Last
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Phone - (###) - ### ####
Email
How do you know this person?
ADDITIONAL INFORMATION
Are you 18 years of age or older? Yes No
If not and you are offered employment, proof of your eligibility to work may be required.
Are you legally authorized to work in the United States? Yes No
If offered employment, you will be required to verify.
When are you available to work?
Are you available to work overtime?
What is your preferred job location?
Will you travel if the job requires?
Where would you like to work? Nursing Home Hospital Doctor's Office Assisted Living Patient's Home Skilled Nursing Other
Do you want: Temporary Full Time Both Temp-To-Full Time
Have you done temporary work before? Yes No
If yes, where?
How did you hear of Stonehouse? Yellow Pages Internet/Newspaper Ad School/College Job Board (ie: Craigslist)
Referral Yes No
Referral Name First Last
Have you applied for a position or worked with us in the past? Yes No
If so, when?
Have you ever been discharged or asked to resign from a job? Yes No
If yes, please explain
Have you ever been bonded? Yes No
Have you ever had your license suspended or revoked? Yes No
If yes, please explain
Do you carry medical malpractice/professional liability insurance? Yes No
If “yes”, please provide carrier and policy number
Have you ever been disqualified or excluded from Medicare (i.e., barred from providing services for a Medicare client)? Yes No
Have you ever been convicted of or pled “guilty” or “no contest” to a crime? Yes No
Note: Stonehouse will not deny employment to any applicant solely because the person has been convicted of a crime. Stonehouse, however, may consider the nature, date and circumstances of the offense as well as whether the offense is relevant to the duties of the position for which you are applying.
Please check the areas in which you have had practical experience. If you have had school experience in a particular area, do not check the box. We will discuss this with you during the interview.
Languages French Japanese Spanish Vietnamese Other Languages
Medical Experience Advanced Cardiac Life Support Acute Care Rehab Basic Life Support Blood Pressure Burn Unit Cardiology Catheter Care Chemotherapy Chiropractic Cardiace Intensive Care Unite Colostomy Maintenance Dental Dermatology Dialysis EKG EKG Interpretations Ear, Nose & Throat Emergency Room Fluency Disorder Gastroenterology Geriatrics Hematology Home Care Hoyer Lift Hospice ICU (Intensive Care Unit) ICU Stepdown Ileostomy Maintenance Internal Medicine Infusaport/Port-a-Cath/Mediport IV (Intra-venous) Joint Replacement Rehab Labor & Delivery Long Term Care Maternity Med/Surg Mental Health Neonatal Neurology NG Tube NICU (Neonatal Intensive Care Unit) Obstetrics & Gynecology Oncology Optometry Ophthalmology Orthopedics Orthoses—Fitting & Training Pediatrics Phlebotomy PICU (Pediatric Intensive Care Unit) Plastic Surgery Protheses—Fitting & Training Pulmonology Radiology Rehabilitation Stress Test Administration Swallow Disorder Telemetry Transplant Spinal Cord Rehabilitation Sonography/Ultrasound Sports Medicine Stroke Rehabilitation Triage Urology Ventilator Management Wheelchair—Training & Fitting
General Office Experience Basic Accounting Advanced Accounting Accounts Payable Account Receivable Customer Service Data Entry Doctor's Office Macintosh Computer Experience Medicaid Experience Medicare Experience Medical Billing Medical Collections Microsoft Office Patient Check-In Patient Check-out PC (Personal Computer) Experience Medical Records Appointment/Patient Scheduling
Please list any additional skills you have (including specific certifications, software package experience, training, etc.):
Please list any special accomplishments, publications, awards, etc.:
Please list any job-related (professional, trade, etc.) organizations to which you belong:
PLEASE READ CARFEULLY BEFORE SIGNING The above information is true and complete to the best of my knowledge. Should I be employed by Stonehouse Staffing, any misrepresentations or false statements contained herein may be considered cause for immediate dismissal. Stonehouse has my permission to obtain all necessary information from the professional licensing and educational institutions, employers and references I have listed, and I release all parties from any possible damages resulting from disclosing such information with or without prior notice to me. I understand that this application does not constitute an employment contract of any kind, and employment is “at-will.” Should I be employed by Stonehouse, I am free to resign at any time, with or without prior notice and Stonehouse may transfer, reassign, suspend, demote or terminate my employment at any time with or without cause and with or without prior notice. I understand that no agreement which is contrary to any of the matters stated above shall be effective unless it is in writing signed by the President of Stonehouse.
Electronic Signature of Applicant *
Date / MM / DD YYYY
Paragraph
Type the letters you see in the image below.

Stonehouse Job Application Form

Stonehouse Job Application Form

PERSONAL INFORMATION

EDUCATIONAL & LICENSING INFORMATION

EMPLOYMENT HISTORY

PROFESSIONAL REFERENCES

ADDITIONAL INFORMATION

Please check the areas in which you have had practical experience. If you have had school experience in a particular area, do not check the box. We will discuss this with you during the interview.