Clinical Employment Application:

Interested in joining the Solaris Family? Please fill out our online application below. You must complete the entire form for us to receive your information.

This category includes RN, Chaplains, Social Workers, CNA, LVN, etc.

 

Personal information
Name *
Name
Address
Address
Primary Phone
Primary Phone
Cell Phone
Cell Phone
Additional Questions
Are you lawfully permitted to work in the United States? *
Have you ever been convicted of a felony? *
Have you ever been convicted of or plead guilty to a crime (excluding misdemeanor traffic violations)? *
Have you ever been involved in the substantial abuse or neglect of children or adults under the laws of this or any other state of the United States? *
Have you ever been sanctioned, cited, reported, or excluded from participation in Medicare, Medicaid, or any other healthcare related law or regulation? *
Have you ever been involuntarily discharged from a position? *
Would you agree to a pre/post drug screening test? *
employment Information
Areas available to work: *
$
Salary type:
Date available to work: *
Date available to work:
Have you ever been interviewed by Solaris Healthcare? *
Have you ever been employed by Solaris Healthcare? *
How did you hear about us?
Education
Did you graduate? *
Did you graduate?
Did you graduate?
Are you currently in school? *
Professional Licenses/Certifications
License Type
Check all that apply
References
Reference #1 *
Reference #1
Phone *
Phone
Reference #2 *
Reference #2
Phone *
Phone
Reference #3
Reference #3
Phone
Phone
Phone
Phone
Work History
May we contact your present employer?
Address 1
Address 1
Phone
Phone
Date started
Date started
$
Date left
Date left
$
Name of supervisor:
Name of supervisor:
Address *
Address
Phone
Phone
Date started: *
Date started:
$
Date left:
Date left:
$
Supervisor *
Supervisor
Address
Address
Phone
Phone
Date started:
Date started:
$
Date left:
Date left:
$
Name of supervisor:
Name of supervisor:
Complete Your Application
I hereby affirm that the information provided on this application is true and complete. I understand that any false or misleading representations or omissions made on the application or during the hiring process may disqualify me from further consideration for employment and may result in discharge even if discovered at a later date. I understand that employment may be conditioned upon successfully passing a medical examination and that I may be required to satisfactorily complete a drug screening as a condition of employment. I hereby authorize persons, schools, my current employer (if applicable), previous employers, and other organizations to provide this facility and its affiliates with any requested information regarding my application or suitability for employment, and I completely release all such persons or entities from any and all liability related to the providing or use of such information. I understand that my employment is at-will which means that I may terminate the employment relationship at any time and for any reason with or without notice, and that this company has the same right. I understand that no one has the authority to enter into any agreement contrary to the proceeding sentence, except for a written agreement signed by an administrative representative of this company and notarized. By signing below, I agree to all of the above and acknowledge that Solaris Healthcare, Inc. may conduct a detailed and thorough investigation which may include but is not limited to a criminal record check, motor vehicle record check, interviews or inquiries of prior employers, coworkers, acquaintances, relatives or friends. I authorize the company to supply my employment record, in whole or in part, and in confidence, to any prospective employer, government agency, or other party, with a legal and/or proper interest.

By checking the box below I agree that I have read the above statements and accept them as conditions of employment with the company. *