Instructions  Please be as thorough as possible in each of your answers. We strongly encourage you to complete each field as we will be better able to determine your fit with our organization. If a question does not apply to you, please use N/A (Not Applicable).

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Select your preferred opening... Allied Health Application Licensed Practical Nurse (LPN) Registered Nurse (RN)

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APPLICANT CERTIFICATION & AGREEMENT: (Read carefully before signing)
I certify that this information contains no willful misrepresentation or falsification and that the information given by me is true and complete to the best of my knowledge and belief. I understand that if employed, misleading or falsified statements on this application may be considered cause for dismissal. I hereby authorize Coastal Healthcare Resources, its affiliates and successors, to obtain any information that may be relevant to an evaluation of my professional qualifications and education, including information pertaining to disciplinary actions, criminal background, drug screen results, work history, education or other confidential or privileged information, and all other credentials.
I authorize Coastal Healthcare Resources to disclose to current, prior, or potential employers making a reasonable inquiry, information relating to my qualifications, ability, and character.
Only to the extent requested and required by the practices, facilities, groups and hospitals staffed by Coastal Healthcare Resources where I will be providing clinical services, I agree to provide and authorize the release of the same by Coastal Healthcare Resources to Coastal Healthcare Resources clients, the following: a) vaccination records; b) reasonable documentation evidencing that I am in good health and free of communicable diseases; c) the result of and/or a copy of my criminal background check, if any and d) the result of and/or a copy of my drug screen, if any.
I hereby release Coastal Healthcare Resources, its officers, employees, and agents, and third parties which provide or receive information regarding my credentials, including, but not limited to, all credentialing information sources, individuals or companies who provide references, companies or agencies that perform clinical background checks, and companies that perform drug screens, from any claims, causes of action, damages and expenses, including reasonable attorney’s fees arising from or relating to the collection, verification, an dissemination of my credentialing and other information.
I agree to hold Coastal Healthcare Resources harmless from and against any and all claims, causes of action, damages, judgments and expenses, including reasonable attorney’s fees, arising from or related to the accuracy of the information provided by me. I understand that this does not contemplate a duty to hold Coastal Healthcare Resources harmless from claims, causes of action and damages which may arise as a result of information provided about me from sources other than me.
This is a continuing authorization and shall be effective from the date of digital e-signature below until such time as I have specifically revoked the same in writing.
If any material changes occur affecting my professional status, it is my obligation to notify Coastal Healthcare Resources or the appropriate affiliate or successor as soon as possible. I understated that the decision to employ me or refer me to practice opportunities is solely at the discretion of Coastal Healthcare Resources.
I understand that any information received from references is confidential and may not be released to me without the consent of the reference. I understand, agree and acknowledge that references are not part of my personnel file. A copy or facsimile of this document shall have the same effect as the original. This document shall be interpreted according to the laws of the state of South Carolina.

Enter your name in the text box below to sign your application and agree to these terms.

Equal Employment Opportunity

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We are an Equal Opportunity employer and do not discriminate on the basis of race, ancestry, color, religion, sex, age, marital status, sexual orientation, national origin, medical condition, disability, veteran status, or any other basis protected by law.

The Information provided will be used for research, reporting, statistical purposes and to monitor legal compliance. To help us comply with these government requirements, please complete the following information.

Completion of this form is voluntary and will not affect your opportunity for employment or terms or conditions of employment if hired. We appreciate your cooperation.

Gender
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Ethnicity
Race (do not respond if you selected "Hispanic or Latino" above)
Protected Veterans
The definitions of protected veterans are listed below. Use the boxes following the definitions to indicate whether you are a protected veteran
Disability Status
You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.

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