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Careerskruller0012020-07-30T12:13:28-04:00
  • PERSONAL INFORMATION


  • DESIRED EMPLOYMENT

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  • CURRENT EMPLOYER





  • EMPLOYMENT HISTORY

  • List your last two (2) employers, assignments of volunteer activities, including experience. Explain any gap in employment in the comments section below.
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY



  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • (Proof of eligibility will be required before employment)




  • EDUCATION

  • High School

  • College | University

  • Professional Training





  • EMERGENCY CONTACT




  • PERSONAL REFERENCES

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • CERTIFICATION

  • SKILLS

  • The following information will help us place you where your skills, knowledge of nursing and preferences will be best suited

  • Preferences




  • If I am employed, I agree to comply with and be bound by the safety and health rules and regulations, and rules of conduct of Excellence Healthcare. This application will remain on active file for 60 days. If I am hired within this period, this form will be transferred to my individual personal file. If I am not hired or have not heard from this agency within 60 days, this application is no longer active and I will need to reapply for employment if I wish to be considered for a job with Excellence Healthcare.

    I do hereby give the employer and/or its agents, including consumer-reporting bureaus, the right to investigate any and all statements made in this application for the purpose of employment and retention of employment. This investigation may include, but not limited to, credit reports, criminal conviction records, motor vehicle driving records and previous employment history. Further, I hereby release from liability and hold harmless Beneficial Support Services ,it’s representative, all persons and organizations/companies for furnishing such information.

    If required, I agree to a drug-testing prior and during employment or for post-accident occurrences. The employer, Excellence Healthcare is an Equal Opportunity Employer. The employer does not discriminate in employment and no questions on this application is used for the purpose of limiting or excusing any applicant’s consideration for employment on a basis prohibited by local, state or federal law.

    NOTICE: This is to inform you that as part of processing your employment application, we may obtain a consumer report, which includes information as to your character, general reputation, personal characteristics and mode of living. If an investigative report is requested, you have the right to make a written request within a reasonable period of time for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation. By signing below, you acknowledge receipt of a copy of this notice and a copy of the “Summary of Your Rights under the Fair Credit Reporting Act.”

  • MM slash DD slash YYYY
  • Please attach photocopies of the following.

    • Birth Certificate
    • Drivers License
    • Copy of Social Security card
    • Employment Authorization/Eligibility
    • CPR Certifications (if any)
    • Professional License (if any)
    • First Aid Certificate(if any)
    • BLS Unrestricted professional Lic (if any)
    • Criminal background check using CJIS
  • Drop files here or
    Accepted file types: pdf, jpg, Max. file size: 64 MB, Max. files: 5.

    LICENSURE

    We are licensed as a Residential Service Agency by the Maryland Department of Health and Mental Hygiene, Office of Health Care Quality.


    MD RSA LICENSE#

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    BUSINESS INFORMATION

    7881 Beechcraft Avenue, Unit B
    Gaithersburg, MD 20877


    Office Tel: 301.977.6000
    Fax: 301.977.5200
    Cell: 240.486.7057


    Hours:
    Mon - Fri: 9:00am - 5:00pm
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