Employment Application

Apply right now on-line; it takes just a few minutes. Your application is the first step toward joining other first class health care professionals who are richly rewarded and professionally empowered.

Complete the application below and submit it to our recruitment staff. To include a resume with your on-line application, e-mail it to one of our recruiters.

Once your application is received, a member of our recruitment team will contact you. Our process is quick and designed for results! We have hundreds of positions in a variety of disciplines and specialties updated weekly.

Feel free to browse our latest offering of available jobs on our Employment Opportunities page or pick up the phone and give us a call.

Fields marked with a star (*) are mandatory

   Name
*First Name
*Last NameMiddile Initial
*E-mail
*Professional discipline *Preferred Shift
SpecialtyDate Available
*Recruiter Name (If not applicable please type "none")
Location desired
Job Number
   Current Address (if other than permanent)
Street Address
CityStateZIP
Home PhoneHow late
Country
Work Phone
Cell Phone
Pager
   Permanent Address
*Street Address
*City*State*ZIP
*PhoneBest time to call
*Emergency Contact*Phone
   Licensure
StateExpiration Date
StateExpiration Date
State Expiration Date
Check One:
 Certified
Registered
Registry Eligible
Other
Certificate: Registration/Registration Number Expiration Date
*Has your professional license or certification ever been investigated or suspended?
Yes
No
If yes, please give details and current status:
*Have you ever been convicted of a crime other than a minor traffic violation?
Yes No
If yes, please give details and current status:
Have you ever been named as a defendant in a professional liability action?
Yes No
*Can you submit verification of your legal right to work in the U.S.?
Yes
No
If you will be employed on a visa, please specify type of work visa:
   Education
College NameCity, State
Diplomas/DegreesGraduation Date
College NameCity, State
Diplomas/DegreesGraduation Date
   Employment History
Please indicate all of your employment for the past ten (10) years, beginning with your most recent employer. Please list each facility in which you have worked.
Are you employed now? Yes No
If so, may we contact your present employer? Yes No
Other names under which you have been employed:

   First Facility/Employer
Facility/EmployerDepartment
Street Address
CityStateZIP
Dates employed:Reason for leaving:
from
to
Position HeldSpecialty
Supervisor's Name and Title Phone
Staff?   Yes No
Travel assignment? Yes No
Local staff agency? Yes No
   Second Facility/Employer
Facility/EmployerDepartment
Street Address
CityStateZIP
Dates employed:Reason for leaving:
from
 to
Position HeldSpecialty
Supervisor's Name and Title Phone
Travel assignment? Yes No
Local staff agency? Yes No
   Third Facility/Employer
Facility/EmployerDepartment
Street Address
CityStateZIP
Dates employed:Reason for leaving:
from
 to
Position HeldSpecialty
Supervisor's Name and Title Phone
Travel assignment?  Yes No
Local staff agency? Yes No
   Fourth Facility/Employer
Facility/EmployerDepartment
Street Address
CityStateZIP
Dates employed:Reason for leaving:
from
 to
Position HeldSpecialty
Supervisor's Name and Title Phone
Travel assignment?  Yes No
Local staff agency?   Yes No
   Fifth Facility/Employer
Facility/EmployerDepartment
Street Address
CityStateZIP
Dates employed:Reason for leaving:
from
 to
Position HeldSpecialty
Supervisor's Name and Title Phone
Travel assignment?   Yes No
Local staff agency?   Yes No
   Sixth Facility/Employer
Facility/EmployerDepartment
Street Address
CityStateZIP
Dates employed:Reason for leaving:
from
 to
Position HeldSpecialty
Supervisor's Name and Title Phone
Travel assignment?  Yes No
Local staff agency?   Yes No
   Seventh Facility/Employer
Facility/EmployerDepartment
Street Address
CityStateZIP
Dates employed:Reason for leaving:
from
 to
Position HeldSpecialty
Supervisor's Name and Title Phone
Travel assignment?   Yes No
Local staff agency?   Yes No
Additional Work Experience / Comments


The information provided in the application for participation in the program is true, correct and complete. I acknowledge that any misstatement or omission of fact on the application may result in my disqualification from participation in the program. I authorize release of this application and reference information to client institutions, only after receiving my express written or verbal consent for each assignment opportunity. I understand that by giving permission to submit my application for assignment opportunities, I am also agreeing to any criminal background investigation that may be required by certain states or client institutions.

Click the Submit button only once. 
It takes a few seconds for the form to be submitted.
After submission you will receive online confirmation.


Richards Healthcare, Inc. is an equal opportunity employer.
Copyright © 2007 Richards Healthcare, Inc. All Rights Reserved.