If you have a background in the medical or healthcare field and would like apply for employment with us, please fill out the information below and we will contact you with the next steps in the process.

Employment Application

First name

Last name

Street address

Phone

Alternate phone number

Social Security number

What position are you applying for?

How long have you been in your field?

Do you have reliable transportation?

What is your expected pay rate?

Please list any license or certifications. (Have proof of documentation)

Please provide two professional references.

Have you ever worked under another name or alias?

Yes

Available start date

Work preferences (check all that apply)

Full time

Part time

On call

What shift/schedule are you interested in?

Day shift

Evening shift

Night shift

Weekends

Have you ever been sanctioned, disciplined, and /or excluded by a duly authorized regulatory agency, or are there any current restrictions or limits on your job-related license(s) or certification(s)?

Yes

N/A

Are there currently any pending actions or active investigations related to a job-related license or certification that you currently hold or held in the past?

Yes

N/A

Additional information

Are you eligible to work in the U.S?

Yes

Federal Law requires proof of U.S citizenship/valid work authorization upon employment.

Are you at least 18 years old?

Yes

Are you currently excluded, debarred, suspended or otherwise ineligible to participate in any Federal healthcare program such as Medicare, Medicaid or TriCare?

Yes

Are you willing to submit to a drug test, background check, and physical examination (if permitted by state law) after you have received a conditional offer of employment?

Yes

Can you perform the essential functions of the job with or without a reasonable accommodation?

Yes

Please provide a brief summary of work-related skills, qualifications, and/or relevant experience related to this position.

Resume/Cover Letter

Upload resume

Upload cover letter (optional)

EEO Information (voluntary)

Gender

Race

Agreement

I hereby certify, that the information provided(and any accompanying documents and/or any additional information requested as part of the application process) is true and complete to the best of my knowledge. I understand that any misrepresentation or failure to disclose information on this form may result in my disqualification from further consideration for employment or, if employed, my termination.

I understand that the satisfactory completion of a background check and drug screen (conducted after an offer of employment) is a condition of employment with Fideli Healthcare Professionals LLC.

By submitting this form, I certify that I have read, fully understand, and accept all terms of the foregoing statement. I consent to conducting this transaction electronically, and I agree that my eSignature has the same force and effect as my handwritten signature on this document.

eSignature (Type full name)

Today's date