ALTA HEALTHCARE SERVICES dba VISTA MEDICAL SOLUTIONS

HIPAA Fax: 240-801-9819

Employment Application

Personal
Yes
No
Yes
No
Male
Female
Job Interest
Full-Time
Part-Time
Per diem
<40/wk
40/wk
>40/wk
Other
Days
Evenings
Nights
Any
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Miscellaneous
Yes
No

Yes
No

Yes
No

Yes
No

Are you related to anyone employed by ALTA HEALTHCARE SERVICES? (To be used for assignment purposes) Name(s) Division/Department Location
Yes
No

Note: The policy of this agency to provide every individual a fair and equal opportunity to seek employment and advancement at the agency without regard to race, color, religion, sex, age, national origin, citizenship status, veteran status, disability or factors protected by state or local laws. "An Equal opportunity Employment Act".

EDUCATION
TYPE OF SCHOOL SCHOOL NAME AND ADDRESS TYPE OF DEGREE EARNED MAJOR YEAR GRADUATED GRADUATED YES/NO
High School
Yes
No
Business Trade, Technical or Vocational
Yes
No
College or University
Yes
No
Do you have further education planned? If so, please explain below:
Professional Licensure/Certification
TYPE NUMBER EXPIRATION CURRENT STATE

List names and addresses of all former employers, beginning with the most recent. (Send additional sheet to careers@altahcs.com if necessary)

Work History
EMPLOYER'S NAME AND ADDRESS BUSINESS NAME DATES OF EMPLOYMENT FROM/TO POSITION/TITLE RATE OF PAY STARTING/LAST REASON FOR LEAVING SUPERVISOR'S NAME, TITLE AND TELEPHONE
Please indicate at least two employers you would prefer us to contact (prior to employment):
List any additional skills, knowledge, experience or other relevant qualifications that might benefit the company:
References
NAME POSITION OR OCCUPATION RELATIONSHIP ADDRESS YEARS KNOWN TELEPHONE
Driver's License
Yes
No

Yes
No

I understand that the information on this application will be used and that prior employers will be contacted for the purpose of investigation.

All Applicants


Please read carefully before signing

I certify that any information I give during the course of applying for employment is true and complete. I understand that any false, incorrect or misleading information or the omission of any pertinent information including that given at the time my application may be considered as sufficient reason for my discharge, if hired. I further understand that this application is not intended to be a contract of employment and that, if I am hired, my employment is at will and can be terminated by either me or the agency, with or without notice, for any or no reason. No supervisor or manager has authority to make an agreement to the contrary changing employment at will. This application will be in effect for 90 days from the date indicated below and, if employment is not offered within the 90-day period, I understand that I must reapply to be considered for future employment. I also understand that this application for employment in no way obligates the agency to employ me.

I hereby authorize ALTA HEALTHCARE SERVICES to investigate my former employment and other references and to make any further investigations deemed necessary in connection with my application for employment and I do hereby release ALTA HEALTHCARE SERVICES and all informants of all liability whatsoever resulting from such investigations.

I understand that an offer of employment I may receive is subject to my subsequent completion, satisfactory to the agency, of all pre-employment procedures, including a drug and alcohol screen test, and submission of documents establishing my rights to work in the USA.