Todays Date
-
Month
-
Day
Year
Date
Current Time
Hour Minutes
AM
PM
AM/PM Option
I am a
RN
LPN
CNA
CMA
EMT
Other
Name
First Name
Middle Name
Last Name
Let's start with some basic contact info and so we can keep in touch!
Email
*
A link will be emailed to you so you can resume this form at any time.
Mobile Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone Carrier
*
Please Select
Verizon
AT&T
T-Mobile
Cingular
Sprint
Boost Mobile
Cricket
Google Fi
Mint Mobile
US Cellular
US Mobile
Visible
Dish Wireless
Reachmobile
Xfinity Mobile
Cordova Wireless
Red Pocket
Tello
Twigby
Birth Date
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Save
Lets Build Your Profile!
We create a profile for you that contains all the information a hospital needs to make the decision to offer you a position. The more complete the profile the more money we can qualify you for. You can always save and continue any question from any point in this app. The profile is made up of documents that prove your qualifications. You can upload them, or take pictures of them with your phone. If you use an iphone, turn off the LIVE feature (we dont need the animation). If you don't have this information, just skip the question and you can come back to it at a later time. This is actually pretty easy, you'll see. Lets get started.
Drivers License - Camera or File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
RN, LPN, CNA License - File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
License State
License Number
Expiration Date
-
Month
-
Day
Year
Date
BLS or ACLS - File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
BLS or ACLS Expiration Date
-
Month
-
Day
Year
Date
Recent Drug Screening - File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Date Of Drug Screening
-
Month
-
Day
Year
Within the last 12 months. If you dont have one we can scheule one for you.
I don't have this... No Problem! We can email or text you an authorization code that can be used at any Concentra location to obtain these tests at no cost to you. Please check all that apply
I need a TSPOT TB Test
I need a Drug Screening
I need a Physical
Other
Do you have a criminal record that may affect employment?
Yes
No
Background Check - File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Date of Background Check
-
Month
-
Day
Year
Date
I don't have this...No Problem!
The easiest way to get one is from the PA state police for $22. Here is the link. https://epatch.state.pa.us/
Child Abuse Clearance - File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
I don't have this...No Problem!
The easiest way to get one is from the PA Child Welfarfe portal for $13. Here is the link. https://www.compass.state.pa.us/cwis/public/home
Resume or Work History - File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Back
Next
Save
Health Forms
Recent Physical - Camera or File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
TB Test Results - Camera or File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Date of TB Test
-
Month
-
Day
Year
Date
Covid Vaccination Card - Camera or File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Date of Last Covid Vaccine
-
Month
-
Day
Year
Date
Documentation of Flu Vaccine - Camera or File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Date of last flu vaccine
-
Month
-
Day
Year
Date
I don't have these. Thats OK, we can Email or Text you an Authorization code that can be used at any Concentra Location to obtain a TB Test at no cost to you. Please check all that apply
I need a TSPOT TB Test
I need a Drug Screening
I need a Physical
Other
I am allergic to Latex:
YES
NO
Back
Next
Save
Hepatitis B Vaccine Declination Statement
I understand that due to my educational and or vocational exposure to blood or other potentially infectious bodily fluids I may be at risk of acquiring hepatitis B virus (HBV). I have been given the opportunity to be vaccinated with hepatitis B vaccine at my own expense.
I have proof of immunity by a positive anti-HBs blood titer, formerly known as the hepatitis B surface antibody (HBSAB).Please indicate which of the following scenarios apply:
Please schedule me to receive the hepatitis B vaccine series.
I am process of getting the hepatitis B series.
I do not want the vaccine.
I decline hepatitis B vaccination at this time as I have proof of immunity by a positive anti-HBs blood titer, formerly known as the hepatitis B surface antibody (HBSAB). I have attempted to find documentation of my prior hepatitis B vaccinations. However, I am unable to find these records at this time.
I have proof of immunity by a positive anti-HBs blood titer, formerly known as the hepatitis B surface antibody (HBSAB).
Hep B Documentation Or Declination
Browse Files
Drag and drop files here
Choose a file
Cancel
of
This statement is not a waiver;
• Employees can request and receive the hepatitis B vaccination at a later date if they remain occupationally at risk for hepatitis B
An employer can not require:
• Employees to waive liability in order to receive the vaccine• Participation in pre-screening as a prerequisite for receiving the vaccine.
Signature
Back
Next
Save
Almost Done... Lets get you Paid !
Here we will gather everything you will need to get paid quickly.
Date Available
-
Month
-
Day
Year
Date
Shift Preferred
Day
Evening
Night
Shift Type
Per Diem
3 month short term contract
6 month contract
Please use the space below to let us know you preferences in terms of Facility, Commute, Restrictions, Pay, Etc.
Social Security Number
Filing Type
Single or Married filing separately
Married filing jointly or Qualifying widow(er)
Head of household (Check only if you’re unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual.)
How many withholdings (dependents)
Signature
Bank Name
Routing Number
Account Number
Drivers License
Save
Submit
Account Type
Checking
Saving
Should be Empty: