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I hereby consent and agree to receive SMS and email communications from Sterling Staffing Solutions pertaining to scheduling and performance-related matters associated with patient care, as well as all other communications related to my employment or contract with Sterling Staffing Solutions. I understand that these communications may include but are not limited to shift assignments, updates, notifications, and important employment-related information. I acknowledge that I can opt out of these communications at any time by following the provided instructions.Terms and Conditions

Name *

First Name

Last Name

Address *

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

Gender *

Clinician Ethnicity *

We’re an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran or disability status.

Date of Birth *

Contact Information

Cell Phone *

(999) 999-9999

Alternate Phone (Home)

(999) 999-9999

Email *

Emergency Contact *

First Name

Last Name

Emergency Contact Cell Phone *

(999) 999-9999

Professional Background

Job Category *

US CITIZENSHIP/ WORK AUTHORIZATION

Please complete the following questions truthfully.

Please answer the following questions:
	Yes	No
Are you a Citizen of the US? *
If not, are you authorized to work in the US? *
Have you ever been convicted of a felony? *
Have you ever worked for this company? *

APPLICATION VALIDITY STATEMENT

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Draw your signature into the box below. *

Special Notes

Please inform SSS of any special circumstances or details HERE that may need to be considered.

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Terms and Conditions:

Name:

Address:

Gender:

Clinician Ethnicity:

Date of Birth:

Cell Phone:

Alternate Phone:

Email:

Emergency Contact:

Emergency Contact Cell Phone:

Job Category:

Contracted Rate Per Therapy EVAL:

Contracted Rate Per Therapy RE-EVAL/DISCHARGE:

Contracted Rate Per Therapy VISIT:

Contracted Rate Per OASIS:

Contracted Rate Per SOC :

Contracted Rate Per ROC:

Contracted Rate-Nurse Discharge:

Specialty:

ZIP CODE COVERAGE AREAS: No Spaces and No Text!!:

Schedule Availability:

Which languages do you speak?:

Are you a Citizen of the US?:

If not, are you authorized to work in the US?:

Have you ever been convicted of a felony?:

Have you ever worked for this company?:

Special Notes:

APPLICATION VALIDITY STATEMENT

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