Providence Health Systems

OVERVIEW

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At PHS we have a proven track record of exemplary service. We are proud to have a vast knowledge and experience of personnel. You can be confident that we are here to help.

* = Required Information

Date

Name *		Home Address *
City *		State *
Home Phone		Cell Phone
Pager		Email *
Social Security #		Job Title
Other Job Title		How did you hear about Providence?
Referred by

JOB INTEREST

Date Available
How many days a week are you interested in working?
Are you interested in covering any on-call shifts including after hours and weekends?
How far are you willing to commute to an assignment?
What shift are you interested in?

PROFESSIONAL LICENSES AND CERTIFICATES

Type of License		Number
State Issued		Expiration
Type of License		Number
State Issued		Expiration

Do you have an ACLS Card?	YesNo	If yes, when does it expire?
Do you have an BLS Card?	YesNo	If yes, when does it expire?

Do you have any other Licenses, Certificates or special training that would be pertinent to the position in which you are applying?

Have you ever been convicted of a felony? If yes, please explain

Are you legally eligible for employment in this country?

Yes No

Attach Resume
Attach Cover Letter

Beyond Excellence

Our strength is in the level of attention and service the PHS team provides on every assignment. PHS has built an organization dedicated to clients who expect and rely on the highest level of service, no matter the size or scope of their needs.