Please check the appropriate box for each question. If you answer "YES" to any of
the following, please use the box provided to describe details.
A) To your knowledge, are you presently the subject of any investigation or
procedure by any agency, registry, or healthcare provider?
B) Are you now, or have you ever been a defendant in any litigation alleging
neglect or impropriety relating to your performance in the field of healthcare?
C) Has any agency, registry, or healthcare facility within the last five (5)
years, cancelled any contract with you as a healthcare professional for any
reason other than at your request?
D) Have you ever been convicted if a crime in the past ten (10) years other
than a traffic violation?
E) During the past ten (10) years, has any license of certification of yours
been cancelled, revoked or refused issue or renewal?
I understand that, if any of the above licensing questions are answered yes, that
ADARA Healthcare Staffing, Inc. has the right to deny this application.
I hereby certify that my answers appearing on this application are true. I
understand that if any material information given in this application is found
to be incorrect or incomplete, it may be grounds for immediate termination at
the sole discretion of ADARA Healthcare Staffing, Inc. I give ADARA Healthcare
Staffing, Inc. the right to contact my previous employers for verification purposes.
I authorize ADARA Healthcare Staffing, Inc., to release any medical information
required for employment to their client facilities. I understand that this information
is scanned and posted on a secured web site that is accessible to their client
facilities and other affiliates of ADARA Healthcare Staffing, Inc.
I understand that this application is not a contract of employment. I also
understand and agree that, if hired, my employment would not be for a definite
period and could be, regardless of the date of payment of my wages and salary,
terminated at any time without any prior notice, with or without any reason.