NTSOC Employment Application


Please answer each question fully and accurately.

Date *
   

Your Information


First Name * Last Name *
 
Street Address *
Address Line 2
City * State/Province/Region *
 
Zip/Postal Code *
Phone *
Other Phone
Email *
Social Security Number *
Last four digits of social security number to verify e-signature
Positon(s) Applying For *
Salary Requirement *
Date Available for Employment
   
Shift Preference *
Day
Evening
Night
Weekend
Are You Seeking *
Regular
Full-time
Part-time
Temporary
Summer only
How did you hear about us? *
Employee Referral
NTSOC Web Site
Social Media Site
Employment Agency
Other Web Site
Other
Referring Employee's Name (If Applicable)
Social Media Site (If Applicable)
Other Web Site (If Applicable)
Do you have any relatives currently on staff? *
Yes
No
Relative Name:
Relationship:
Are you 18 years of age or older? *
Yes
No
If hired you may be required to provide proof of age.
Have you ever filed an application with NTSOC? *
Yes
No
Have you ever been employed with NTSOC before? *
Yes
No
If yes, when?
Are you on lay-off subject to recall? *
Yes
No
Are you on a lay-off subject to recall? *
Yes
No
Have you ever been convictedof a felony? *
Yes
No
Include any plea of "guilty" or "no contest." Exclude minor traffic violations.
Conviction Information
Please give the date, place and nature of the charge of which you were convicted. (A conviction will not necessarily disqualify you from employment.)
If hired, can you furnish proof that you are eligible to work in the United States? *
Yes
No
(Employment is contingent upon staisfactory proof of eligibility to work in the United States.)
Have you worked or attended school under any other name? *
Yes
No
Give name(s)
May we check your present employer for a reference? *
Yes
No

Skills and Qualifications


Please list any licenses, certifications or registrations you may have. *
 
Skill Summary
Years of experience in this field?
Clinical Areas Preferred

Employment Experience


PLEASE COMPLETE THIS SECTION EVEN IF YOU PLAN TO ATTACH A RESUME.  List your last three employers, beginning with the most recent. Account for all periods of time including military service and periods of unemployment.
Name of Employer

Employer Address


Street Address
Address Line 2
City State/Province/Region
 
Zip/Postal Code Country
 
Employer Telephone Number

Date of Employment

From To
 

Rate of Pay

Starting Pay Ending Pay
 
List Duties
Job Title
Status
Full-time
Part-time
Temporary

Supervisor's Name

First Last
 
Reason for leaving or wanting to leave?


Name of Employer


Employer Address
Street Address
Address Line 2
City State/Province/Region
 
Zip/Postal Code Country
 
Employer Telephone Number

Date of Employment

From To
 

Rate of Pay

Starting Pay Ending Pay
 
List Duties
Job Title
Status
Full-time
Part-time
Temporary
First Last
 
Reason for leaving or wanting to leave?


Name of Employer

Employer Address


Street Address
Address Line 2
City State/Province/Region
 
Zip/Postal Code Country
 
Employer Telephone Number

Date of Employment

From To
 

Rate of Pay

Starting Pay Ending Pay
 
List Duties
Job Title
Status
Full-time
Part-time
Temporary

Supervisor's Name

First Last
 
Reason for leaving or wanting to leave?

Education


Highest Grade Completed

High School
9
10
11
12
College
1
2
3
4
Graduate School
1
2
3
Apprentice, Business, or Vocational School

Schools Attended

School and Location Major
 
Diploma/Degree Graduated (yes/no)
 

References



Reference #1

Name * Relationship/Organization *
 
Contact Information * Years Known *
 
List those familiar with your job performance, personal characteristics and who have known you a minimum of one year. Do not list relatives. Note: A job offer may be contingent upon acceptable references.

Reference #2

Name * Relationship/Organization *
 
Contact Information * Years Known *
 

Reference #3

Name Relationship/Organization
 
Contact Information Years Known
 

Reference #4

Name Relationship/Organization
 
Contact Information Years Known
 

PLEASE READ EACH STATEMENT CAREFULLY BEFORE SIGNING

I certify that all information provided in this application and any attachments is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment, or, if I am hired, may result in my dismissal from employment if discovered at a later date.
I understand that the employer may request an investigative consumer report from a consumer-reporting agency. This report may include information as to my character, reputation, personal characteristics and mode of living obtained from interviews with neighbors, friends, former employers, schools and others. I understand I have a right to make a written request within a reasonable time for the disclosure of the name and address of the consumer-reporting agency so that I may obtain a complete disclosure of the nature and scope of the investigation.

I authorize the investigation of any or all statements contained in this application. I also authorize, whether listed or not, any person, school, current employer, past employers, and organizations to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements.

I understand that this application or subsequent employment does not create a contract of employment nor guarantee employment for any definite period of time. If employed, I understand that I have been hired at the will of the employer and that my employment may be terminated at any time, with or without cause and with or without notice. I understand that no employee or representative of NTSOC, Inc. other than the Human Resources Representative has any authority to enter into any agreement for employment for a specified period of time or to make any agreement contrary to the foregoing. Further, the Human Resources Representative may not alter the at-will nature of the employment relationship unless done so specifically and in writing. I have read, understand and consent by my signature to these statements.
Signature *
Signature Date *
   


Equal Employment Opportunity



It is Nursing & Therapy Services of Colorado’s policy to provide equal employment opportunity to all persons regardless of their race, sex, color, national origin, age or disability. For this reason, we invite you to voluntarily complete this form to provide the information needed for us to comply with record keeping and reporting requirements. Completion of this data is voluntary and will not affect your opportunity for employment, or terms or conditions of employment. This form will be used for reporting purposes only and will be kept separate from all other personnel records only.
Date *
   
 
Position Applied For *
 

Name

First * Last *
 
Social Security Number *
 
Gender *
Male
Female
I choose not to disclose
 
Race *
Hispanc or Latino
White (Not Hispanic or Latino)
Black or African American (Not Hispanic or Latino)
Asian (Not Hispanic or Latino)
Americn Indian (Not Hispanic or Latino)
Two or more races (Not Hispanic or Latino)
I choose not to disclose
Mental or Physical Disability? *
Yes
No
I choose not to disclose
Disabled Veteran? *
Yes
No
I choose not to disclose
Vietnam Veteran? *
Yes
No
I choose not to disclose

DISCLOSURE AND AUTHORIZATION FORM TO OBTAIN CONSUMER REPORTS FOR EMPLOYMENT PURPOSES



Please read carefully before signing the authorization

Disclosure

In considering you for employment and, if you are employed, in considering you for subsequent promotion, assignment, reassignment, retention, or discipline, Nursing & Therapy Services of Colorado, Inc. may request and rely upon one or more consumer reports or investigative consumer reports about you that we obtain from a consumer reporting agency, such as IntelliCorp Records, Inc.

For explanation purposes:



  • A "consumer report" is a written, oral or other communication of any information by a consumer reporting agency bearing on your credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living which is used or expected to be used as collected in whole or in part for the purpose of serving as a factor in making an employment-related decision about you. Such information may include, for example, credit information, criminal history reports, or driving records; and
  • an "investigative consumer report" is a consumer report in which inforamtion on your characeter, general reputation, personal characteristics, or mode of living is obtained through personal interviews with your prior employers, neighbors, friends, or associates. or with others who may have knowledge concerning any such items of information. In the event an investigative consumer report is requested about you, you are entitled to additional disclosures regarding the nature and scope of the investigation requested, as well as a written summary of your rights under the Fair Credit Reporting Act ("FCRA").


Under the FCRA, before the Company can obtain a consumer report or investigative consumer report about you for employment purposes, we must have your written authorization. before we take adverse action on the basis, in whole or in part, of information in that report, you will be provided a copy of that report, the name, address and telephone number of the consimer reporting agency, and a summary of your rights under the FCRA


Authorization



I have read and understand the foregoing Disclosure, and authorize Nursing & Therapy Services of Colorado, Inc. to obtain and rely upon consumer reports or investigative consumer reports in considering me for employment and, if I am employed, in considering me for subsequent promotion, assignment, reassignment, retention, or discipline. By my signature below, I authorize the Company to obtain any such reports and to share the information received with any person involved in the employment decisions about me.
I _______ authorize you to contact my current employer for Employment and Reference Verifications *
do
do not
(This will authorize immediate inquiries to the Human Resources Department and to any listed supervisors or references in the Employment/Reference section of your application)


I also agree that this Disclosure and Autorization in original, faxed, photocopied or electronic (including electronically signed) form will be valid for any consumer reports or investigative consumer reports that may be requested about me by or on behalf of the Company.

Electronic Signature

First * Last *
 
Social Security Number *

Parent or Legal Guardian Electronic Signature

First Last
 
(for searches conducted on minors under the age of 18)
Date *
   

Personal Data



 

Name

First * Last *
 

Current Address

Street Address *
Address Line 2
City * State/Province/Region *
 

Dates at current address

From To
 

Previous Address #1

Address * Move In/Move Out Dates *
 
Please list addesses for previous 7 years.

Previous Address #2

Address Move In/Move Out Dates
 
Please list addresses for previous 7 years.

Previous Address #3

Address Move In/Move Out Dates
 
Please list addresses for previous 7 years.

Previous Address #4

Address Move In/Move Out Dates
 
Please list addresses for previous 7 years.
Date of Birth *
   
Other Names Used
Social Security Number *
Drivers License # *
Drivers License State *
Email *
May be used for official correspondence
 


I have the right to make a request to IntelliCorp Records, Inc, upon proper identification, to request the nature and substance of all information in its files on me at the time of my request, including sources of information, and the recipients of any reports on me which IntelliCorp Records, Inc has previously furnished within the two year period preceding my request.

I certify that all of the elements of the personal data I have provided are true, accurate and complete, I understand and agree that any omission, false statement, misleading statement, or answer made by me on my application or any supplements to it and in any interviews will be sufficient grounds for rejection of employment and my discharge after employment.

Electronic Signature

First * Last *
 
Last Four Digits of Social Security Number *
Date *