You are submitting this information over a secure connection. (Items marked with an asterisk * are required.)
Contact
  *Last Name *First Name Middle Name Other Names Used
 Name:
  Street Address Suite City St Zip
 Office: 
  *Street Address Appt *City *St *Zip
 Home:
*Preferred contact method:  
  Office Office Fax   *Home   Cell
  Phone Numbers:     
*Email Address:       * Confirm Email: 
*Best time to reach me: 
  Month Day Year  
When would you be available to begin work?
*My Search is: 
Personal
*Are you legally eligible for employment in the United States?   Visa Status (if applicable)
Do you have any relatives currently employed by Saint Francis Health System?
Have you ever been convicted, been given probation or deferred adjudication in lieu of sentencing, or pled no contest for any offense other than a minor traffic offense (including Military Service)?
(Saint Francis Health System conducts background checks. Failure to divulge complete information will disqualify you from employment. However, conviction will not necessarily disqualify an applicant from employment.)
Are you charged with an unresolved criminal charge? (Are you charged with a crime that has not yet resulted in a plea of guilty, court trial, deferred adjudication or dropping of the charge? )
Are you currently or have you ever been sanctioned, suspended, terminated or excluded from participation as a Medicare or Medicaid/AHCCCS provider?
Have you directly or indirectly, through another person or entity, ever been convicted of a criminal offense in healthcare?
Are you presently or have you ever been charged, convicted, been given probation or deferred adjudication in lieu of sentencing, or pled no contest of any crime related to your clinical practice?
Licenses
      Month Year
 OK License#:  Exp. Date: I have applied for this license: 
  (Attach scanned copy if available.)
    
      Month Year
 DEA License#:  Exp. Date: I have applied for this license: 
  (Attach scanned copy if available.)
    
  State Number   Month Year
 Out of State License:      Exp. Date:
  State Number   Month Year
 Out of State License:      Exp. Date:
Certifications
  Name   Month Year   Month Year
 Specialty:      Board Cert Date:     ReCert Date:
  Name   Month Year   Month Year
 SubSpecialty:      Board Cert Date:     ReCert Date:
*Insurance
  Carrier Name Policy Number Mailing Address
 Malpractice:   
(Attach scanned copy of your malpractice insurance policy certification if available.)
    
 
*Professional Education
  Name Address
College or Univ:
  From (YYYY) To (YYYY)   Month Year
Attended:    Graduated:    *Degree:
Post Graduate Education
  Name Address
 Institution:
  From: Month Year   To: Month Year   Month Year Course of Study  
Attended: -     Graduated:
 
Degree Granted/Program Completed?     Preceptor/Program Director:
  Name Address
 Institution:
  From: Month Year   To: Month Year   Month Year Course of Study  
Attended: -     Graduated:
 
Degree Granted/Program Completed?     Preceptor/Program Director:
*License Issues
 
Have you ever had any action taken against your professional license?

Have you been subjected to or have any of the following ever been or are in the process of being
denied, revoked, suspended, limited, reduced, not renewed or relinquished (whether by resignation or
expiration, voluntarily or involuntarily)?
Narcotic License, Drug Enforcement Administration or other controlled substances registration
License to practice medicine in any jurisdiction
Staff appointment status or clinical privileges at any hospital, clinic or healthcare institution
Status as a student or participant in good standing in any clinical school, internship, residency, fellowship,
preceptorship, or other clinical education program
*Legal Issues
 
Have you ever been charged, pled guilty, been found guilty and/or convicted of a felony?
 
Have you ever been charged, pled guilty, been found guilty and/or convicted of a crime involving abuse,
dishonesty or moral turpitude (i.e. theft, embezzlement, fraud, battery, assault, rape, molestation,
or indecent exposure, etc.)?
 
Are you presently or have you ever been charged with or convicted of any crime related to your clinical
practice?
 
Has your professional liability insurance ever been cancelled or has professional liability insurance ever 
been denied?
 
Have any professional liability claims, judgments or settlements been made involving you within the past ten    
years?
*Employment History
If you were employed under a different name, please enter it here:
 
Present or most recent employment:
*Company Name:
  *Street Address Suite *City *St *Zip
*Company Address:
*Employer's Phone Number:    *May we contact this employer for a reference?  
*Professional References
  Name Position
Contact:
  Street Address Suite City St Zip
Office: 
  Work Phone Alt Phone Fax email
 
  Name Position
Contact:
  Street Address Suite City St Zip
Office: 
  Work Phone Alt Phone Fax email
 
  Name Position
Contact:
  Street Address Suite City St Zip
Office: 
  Work Phone Alt Phone Fax email
 
 
Attach your CV
Attach your CV      
Attach any other file      
*Affirmation
Read the following carefully before signing.
I understand and agree that if employed by Saint Francis Health System, that Saint Francis Health System may conduct inquires into my criminal records at any time and that the inquiry could be for any reason.

Sex Offender / Violent Crime Offender

As the result of the law passed by the Oklahoma legislature all person(s) who work with or provide services to children, are now required to affirm through a signed statement that he or she is not required to register with either the Oklahoma Sex Offenders Registry or the Violent Crime Offenders Registry.
I hereby declare my registration status under the

  • Oklahoma Sex Offenders Registration Act, or
  • Mary Rippy Violent Crime Offenders Registration Act.

    •      

I agree that the information contained on this application is true and correct. I understand that omission, misrepresentation, or falsification of information is grounds for withdrawal of any job offer, or for immediate discharge. I understand that employment is contingent upon receipt of satisfactory references, and the following, a post job offer health screen, licensure verification and proof of identity and authorization to work in the United States. Pursuant to the requirements of the Fair Credit Reporting Act, notice is given that a consumer report may be made in connection with my application for employment. If I am denied employment, either wholly or partly, because of information contained in a consumer report, a disclosure will be made to me of the name and address of the consumer reporting agency making such report.
*Authorization for Release of Information
I authorize Saint Francis Health System, and/or its delegated representative(s) to consult with and seek information from educational facilities, medical practitioners, or hospitals with which I have been associated and\or others who may have information bearing on my professional ability and qualifications. I understand that such investigations may include, but are not limited to, query of the National Practitioner Data Bank, American Medical Association, Federation of State Medical Boards, DEA, and verification of licensure with appropriate state medical boards. I further authorize Saint Francis Health System and/or its delegate, to obtain information regarding my present and past liability insurance coverage, including claims, suits, and settlements made, concluded or pending.

I understand that employees and applicants for employment with Saint Francis Health System employers ("Health System") are subject to prohibitions in the use and misuse of an illicit drug, alcohol, legal drug and controlled substance (collectively "drug and alcohol"). These prohibitions are set forth in the Drug and Alcohol Policy of the Health System Policy Manual (the "Policy").

I further understand that my testing information may be released to healthcare oversight or licensing agencies or other parties, as required or permitted by law.

I understand that Saint Francis Health System is a tobacco-free employer. Saint Francis Health System is an affirmative action and equal opportunity employer.

I further understand that employment, unless otherwise governed by a specific written employment agreement, is at will, and that I or Saint Francis Health System may terminate the employment relationship at any time, with or without notice and with or without reason.
My typed name below shall have the same force and effect as my written signature.
Applicant's Signature:
FCRA NOTICE AND ACKNOWLEDGMENT
IMPORTANT -- PLEASE READ CAREFULLY BEFORE SIGNING ACKNOWLEDGMENT
NOTICE REGARDING BACKGROUND INVESTIGATION
Employer (�the Company�) may obtain information about you from a consumer reporting agency for employment purposes. Thus, you may be the subject of a �consumer report� and/or an �investigative consumer report� which may include, but is not limited to: employment and education verifications; social security number verification; criminal and civil court records; personal interviews; driving records; and/or any other public records or any other information bearing on my character, general reputation, personal characteristics and trustworthiness. These reports may be obtained at any time after receipt of your authorization and, if you are hired, throughout your employment. You have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report.

The report will be generated by Universal Background Screening (7720 North 16th Street, Suite 200, Phoenix, AZ 85020, 1-877-263-8033) or another outside organization. The scope of this notice and authorization is all-encompassing, however, allowing Employer to obtain from any outside organization all manner of consumer reports and investigative consumer reports now and, if you are hired, throughout the course of your employment to the extent permitted by law. As a result, you should carefully consider whether to exercise your right to request disclosure of the nature and scope of any investigative consumer report.
 
New York applicants only: You have the right to inspect and receive a copy of any investigative consumer report requested by the Company by contacting the consumer reporting agency identified above directly.
 
ACKNOWLEDGMENT AND AUTHORIZATION
I acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION (above) and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT (separate document) and certify that I have read and understand both of those documents. I hereby authorize the obtaining of �consumer reports� and/or �investigative consumer reports� at any time after receipt of this authorization and, if I am hired, throughout my employment. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by Universal Background Screening, another outside organization acting on behalf of Employer, and/or Employer itself. I agree that a facsimile (�fax�) or photographic copy of this Authorization shall be as valid as the original.
 
Oklahoma applicants only: Please check this box if you would like to receive a copy of a consumer report if one is obtained by the Company.
 
Applicant's Signature Date
  Month Day Year  
*Date of Birth:     *SSN:     Driver License #/State: