AHT, Ltd. (Allied Healthcare Temps) 1 Westbrook Corporate Ctr. Suite 300 Westchester, Illinois 60154
p:	(800)633-7821
f:	(630)928-0117
e:	info@ahtemps.com

online application

Personal Information:
Name:
Address:
City:
State:
Zip Code:
Phone:
E-mail:
Social Security #:
Best Time To Call:
Referred By:

Emergency Contact Information:
Name:
Phone:

Education:

College:

Name/Location of School	Year Graduated	Type of Degree

Med/Training:

Areas Of Preference:
Please check the area(s) that best match(es) your education, experience and interest.
Supplemental Staffing Support
	Nursing	Allied Health
	Physician	Medical Office
	Hospital	Nursing Home
	Geriatric	Psychiatric
	Labor/Delivery	Med/Surg
	Pediatric/Maternal Child	ICU/CCU
	Clinic (Specify)
	Other Specialty:
Please check the shift(s) and days of the week you are available or prefer to work:
	Full-time	Monday
	Part-time	Tuesday
	7AM-3PM	Wednesday
	3PM-11PM	Thursday
	11PM-7AM	Friday
	7AM-7PM	Saturday
	7PM-7AM	Sunday
	Other

License/Certification:
License Type:	License/Certification	State



CPR Expiration Date:
Last TB/CXR Date:

Medical History:

Condition Of Health:

Date Of Last Physical:

Have You Ever Applied For Or
Received Workers Compensation?

Y N

If Yes, Give Description Of Claim:

List Any Chronic Illness Or Infirmity:

Have you Ever Been Convicted
Of A Felony?

Y N

Have You Ever Been Convicted Of A Drug Related Misdemeanor?

Y N

Are You Legally Authorized To
Work In The USA?

Y N

Previous Employment:
Employer:
Address:
City:
State:
Zip Code:
Phone:
Immediate Supervisor:
Specialty:
Position Held:
Dates Of Employment:	From: to
Shift:
Reason For Leaving:

Employer:
Address:
City:
State:
Zip Code:
Phone:
Immediate Supervisor:
Specialty:
Position Held:
Dates Of Employment:	From: to
Shift:
Reason For Leaving:

Employer:
Address:
City:
State:
Zip Code:
Phone:
Immediate Supervisor:
Specialty:
Position Held:
Dates Of Employment:	From: to
Shift:
Reason For Leaving:

Employment History :

Have you Ever Applied For Or
Received Unemployment Compensation?

Y N

If Yes, Explain With Dates
And Employers:

Submit Form:

I certify that the information in this application in accurate, current and complete. I understand that misstatements or omissions may result in disqualification from further consideration or termination of employment.

I authorize AHT, Ltd. (Allied Healthcare Temps) , Ltd. to investigate my employment history, credentials and to obtain any relevant information (including a criminal and abuse background checks) needed to make an employment decision. I authorize AHT, Ltd. (Allied Healthcare Temps) , Ltd. to disclose this application along with any information about me obtained through reference checks or during the course of the interview process for state, federal, contractual or accreditation audit purposes. I also authorize AHT, Ltd. (Allied Healthcare Temps) , Ltd. to disclose any of my performance appraisals, disciplinary records or skills tests for the same purposes as above. I release AHT, Ltd. (Allied Healthcare Temps) , Ltd. and any individual or entity providing information to AHT, Ltd. (Allied Healthcare Temps) , Ltd. from all liability for any damages from the disclosure of this information.

I also understand and agree that:

	passing a medical examination and/or participating in a post-conditional offer medical screening may be required. If medical restrictions cannot be reasonably accommodated, I may not be hired, or if hired, employment may be terminated.
	I may be subject to pre-employment drug testing, or a drug test where a reasonable suspicion exists, or where warranted by circumstances, workplace conditions or contractual requirements.

I understand and agree that nothing contained in this employment application or in granting of an interview creates an employment contract between AHT, Ltd. (Allied Healthcare Temps) , Ltd. and myself for either employment or for the providing of any benefit. No promises regarding employment have been made to me. If an employment relationship is established, I understand that I will have the right to terminate my employment at any time, and that AHT, Ltd. (Allied Healthcare Temps) , Ltd. will retain a similar right to terminate my employment at any time.

I understand that should I become employed by AHT, Ltd. (Allied Healthcare Temps) , Ltd., my work assignments, schedules and/or work locations are subject to change according to the needs of the business and the clients of AHT, Ltd. (Allied Healthcare Temps) , Ltd..

By clicking "I Agree" it is acknowledged that the above information is correct and the General Terms are accepted.