Join the Healthcare Staffing Team

Welcome! We appreciate your interest in joining the HMT Healthcare LLC Staffing agency team!

Please complete this employment application form for consideration. We strongly suggest proof-reading your application before clicking the submit button. Once submitted your application is final.

You may save and continue progress on this application at any time. Click “Exit and save my progress” at the bottom of the page, enter your email address and you will receive a temporary link via email to continue this form.

We look forward to working with you!

BECOME AN EMPLOYEE

REQUEST STAFF

TODAY’S DATE: *

(DD/MM/YYYY)

NAME *

Last Name *

Address *

Street Address

City *

Postal/Zip code

State/province *

Country *

Contacts (Please put N/A where not applicable, Don't leave Blank.) *

Phone *

Alternative Phone

Email Address *

PLEASE PLACE A CHECK MARK BY YOUR RESPONSE OR PROVIDE THE APPROPRIATE INFORMATION

What Region/City will you be working in? *

What schedules would you prefer?

Full Time Part Time Temporary Weekdays Evenings Nights

Have you worked for this company before: *

Yes No

Do you know anyone who works here? : *

Yes No

How did you hear about us? *

Walk In Referral Adverts Other

Date *

dd-mm-yyyy

Name of employee:

Desired Pay: $

Desired pay Annual:$

Desired Annual Pay

When are you able to start work?: *

(DD/MM/YYYY)

In what local area do you prefer to work?

Position Desired:

Are you authorized to work in the United States? *

Yes No

Federal law requires that emplyers hire only individuals who are authorized to be lawfully employed in the United States. In compliance with these laws, Excellent Nursing Services will verify the status of every individual offered emplyment with the Company. In this connection, all offers of employment are subject to verification of the applicatn’s identity and emplyment authorization, and it will be necessary for you to submit such documents as required by law to verify your identification and emplyment authorization.

HMT Healthcare Services Inc. is an equal opportunity employer and does not discriminate against any applicant or employee because of race, color, religion, sex, national origin, disability, age, or military or veteran status in accordance with federal law. In addition, HMT Healthcare Services Inc. complies with applicable state and local laws governing non-discrimination in employment in every jurisdiction in which it maintains facilities. HMT Healthcare Services Inc. also provides reasonable accommodation to qualified individuals with disabilities in accordance with applicable laws.

Are you under 18 years of age? *

Yes No

Are you capable of performing the essential functions of the job for which you are applying with or without a reasonable accommodation?

Yes No

If yes, can you furnish a work permit? :

Yes No

LIST YOUR EXPERIENCE BELOW (MOST RECENT JOB FIRST)

Massachusetts applicants may include any verified work performed on a volunteer basis

COMPANY NAME # 1

FROM *

Month / Year

SUPERVISOR’S NAME, TITLE, POSITION

COMPANY ADDRESS

YOUR POSITION AND TITLE

TO *

Month / Year

SUPERVISOR’S TELEPHONE NUMBER

City

State/province

Zip Code

TYPE OF BUSINESS

HOW DID YOU LEAVE YOUR JOB ?

Voluntary

Involuntary

TELEPHONE NUMBER

REASON(S) IF YOU WERE TERMINATED

BRIEFLY DESCRIBE YOUR MAJOR DUTIES

Massachusetts applicants may include any verified work performed on a volunteer basis

COMPANY NAME # 2

FROM

Month / Year

SUPERVISOR’S NAME, TITLE, POSITION

YOUR POSITION AND TITLE

Month / Year

SUPERVISOR’S TELEPHONE NUMBER

COMPANY ADDRESS

City

State/province

Zip Code

TYPE OF BUSINESS

HOW DID YOU LEAVE YOUR JOB?

Voluntary

Involuntary

TELEPHONE NUMBER

REASON(S) IF YOU WERE TERMINATED

BRIEFLY DESCRIBE YOUR MAJOR DUTIES

EDUCATION

HIGH SCHOOL OR PREP

MAJOR SUBJECT

DID YOU GRADUATE

TYPE OF DEGREE/DIPLOMA

COLLEGE

MAJOR SUBJECT

DID YOU GRADUATE

TYPE OF DEGREE/DIPLOMA

COLLEGE OR GRADUATE

OTHER QUALIFICATIONS

MAJOR SUBJECT

DID YOU GRADUATE

TYPE OF DEGREE/DIPLOMA

PROFESSIONAL DESIGNATIONS

DESIGNATION

GRANTED BY: (Organization)

DATE COMPLETED *

DD/MM/YYYY

DATE COMPLETED *

(DD/MM/YYYY)

PROFESSIONAL LICENSES

TYPE OF LICENSE

STATE GRANTING LICENSE

LICENSE NUMBER

MILITARY SERVICE

Have you served in the military?

Yes No

Dates of service:(dd/mm/yyyy)

List of skills acquired that relate to the position being applied for:

REFERENCES: Please list three professional references

NAME

COMPANY

NAME

COMPANY

NAME

COMPANY

RELATIONSHIP

PHONE / ALTERNATE PHONE

RELATIONSHIP

PHONE / ALTERNATE PHONE

RELATIONSHIP

PHONE / ALTERNATE PHONE

EMERGENCY CONTACT INFORMATION

NAME

PHONE NUMBER

RELATIONSHIP

PLEASE READ EACH STATEMENT CAREFULLY BEFORE SIGNING

I certify that all information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date.

I authorize the investigation of any or all statements contained in this application. I also authorize, whether listed or not, any person, school, current employer, past employers and organizations to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements.

I understand that I will be required to successfully pass a drug screening examination. I hereby consent to a preemployment drug screen.

I understand that if I am extended an offer of employment, it will be considered conditional upon my successfully passing a complete pre-employment physical examination. I consent to the release of any or all medical information as may be deemed necessary to judge my capability to do the work for which I am applying.

I understand that this application, verbal statements by management or subsequent employment does not create an express or implied contract of employment nor guarantee employment for any definite period of time.

If employed, I understand that I have been hired at will and that my employment may be terminated at any time, with or without reason and with or without notice.

I have read, understand, and by my signature consent to the above statements

Name *

Date *

(DD/MM/YYYY)

HMT BACKGROUND CHECK INFORMATION

The information requested below is collected solely for aiding the Company in running background check in connection with your application for employment. The employer is requesting
that your provide this information to assist in conducting a thorough background check.

FIRST NAME *

For Identification Purposes Only: Date of Birth *

(DD/MM/YYYY)

LAST NAME *

PERSONAL INFORMATION

SOCIAL SECURITY NUMBER *

Race *

Hispanic/Latino American Indian Asian Black/ African American White

Others

DRIVER'S LICENCE NUMBER *

STATE ISSUING LICENCE *

Address writing the past years

PRESENT ADDRESS *

STREET ADDRESS

CITY *

ZIP CODE *

START DATE *

From (MM/YYYY)

State/province *

END DATE *

From (MM/YYYY)

ADDRESS #2 *

STREET ADDRESS

CITY *

ZIP CODE *

START DATE *

From (MM/YYYY)

State/province *

END DATE *

From (MM/YYYY)

TO ALL NURSING NEW HIRES

DATE

Dear Applicant,
Thank you for your interest in HMT Healthcare services.
Attached you will find several pre-employment forms to complete at your earliest
convenience. Once complete please fax forms to +1(800)-606-3410 or scan and email
to career@hmthealthcare.com.You may optionally upload your copies below.

Please include the following with your application:

1) A copy of your current TB test

2) A recent employment physical

3) A copy of your certificate/license

4) A copy of your vaccinated card/exemption for

5) A copy of your social security card

Once these forms are received we will set up a date and time for an interview.
We look forward to adding you to our team.
Sincerely,

HR Director.

Message / Comments

BECOME AN EMPLOYEE

Join the Healthcare Staffing Team

LIST YOUR EXPERIENCE BELOW (MOST RECENT JOB FIRST)

EDUCATION

PROFESSIONAL DESIGNATIONS

PROFESSIONAL LICENSES

MILITARY SERVICE

REFERENCES: Please list three professional references

EMERGENCY CONTACT INFORMATION

PLEASE READ EACH STATEMENT CAREFULLY BEFORE SIGNING

HMT BACKGROUND CHECK INFORMATION

PERSONAL INFORMATION

Address writing the past years

TO ALL NURSING NEW HIRES

Information Summary

Useful Links

Business Hours