EHS Application
Please fill out the form below accurately indicating your interest and suitability for the positions offered.
Name:
*
First Name
Middle Name
Last Name
Phone Number:
*
How did you hear about us?
*
Indeed (other employment website)
Website/Google
Social Media
Referred by Family/Friend
If referred by Family/Friend, please tell us who.
Name and Title
May we text you at this number?
*
No
Yes
Not a mobile phone
E-mail Address:
*
example@example.com
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
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28
29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
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2015
2014
2013
2012
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2002
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1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Social Security Number
*
Please provide your social security number for proof of identity.
Driver's License Number
*
DL State
*
DL Expiration Date
*
-
Month
-
Day
Year
Date
Which position are you interest in?
*
Registered Nurse (RN)
Licensed Practical Nursing (LPN)
Certified Nursing Assistant (CNA)
Patient Care Assistant (PCA)/ Sitter
Other
Specialty
*
LTC/SNF
Med-Surg
Telemetry
Trauma ICU
Med-Surg ICU
Critical Care
Emergency Department
Psychology
Cardiac Care
N/A
Other
Available Start Date
*
-
Month
-
Day
Year
Date
Desired Shift
*
7a- 3p
3p-11p
11p-7a
7a-7p
7p-7a
Any
Position applying for (check all that applies)
*
Per Diem (PRN)
Part-Time
Full-Time
Local/Travel Contract
Are you able to perform the basic functions of the position for which you are applying without any restrictions?
*
Yes
No
Please Upload at Least (2) Professional References
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You can also email your professional references to fsavage@essentialhservices.com
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Updated Resume
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Updated within the last 6 months
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By providing your signature, you understand that all positions applied for are, contracted, as needed, and/or on call positions. The filling out of this application does not guarantee you a position with Essential Healthcare Services nor does it stand as a commitment on your part. It is our company policy to comply with all applicable state and federal laws prohibiting discrimination in employment based on race, age, color, sex, religion, national origin, disability or other protected classifications.
*
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EHS On-Boarding
Emergency Contact
*
First Name
Last Name
Emergency Contact
*
Phone Number
Driver's License/ ID
*
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Social Security Card
*
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COVID Card/Exemption
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Please upload a copy of your COVID card or COVID Exemption (if applicable)
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Updated Physical (within 1 year)
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TB Results
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Professional License/Certification
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Please upload a copy of our Professional License or Certification
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Name of the Institution
Name of the Institution of which you obtained your professional license or certificate.
Location of Institution
City and State of the Institution of which you obtained your professional license or certificate.
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