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PERSONAL DATA

First name *

Last name *

Middle Initial

Maiden Name

Primary Phone *

Secondary Phone

Date of Birth *

Are you a citizen of the United States:

YES

NO

User Name/Password

Create a User ID *

Email address *

Password *

Confirm password *

ADDRESS

Street *

Apt# / PO#

City *

State *

Zip Code *

Have you lived out the state of PA within the last 2 years

YES

NO

EDUCATION

Name of School *

Highest Level of Education Completed *

Have you completed graduation ?

YES

NO

Name of School	Education Completed	Action

WORK EXPERIENCE (Minimum of 1 year related experience.)

Name of Organization *

Discipline *

Employment Date *

Currently Employed

Name of Organization	Discipline	Start Date	End Date	Action

How did you hear about us

Comments

RELEASE AND AUTHORIZATION

I hereby affirm that the information provided in this application and accompanying documents is true and complete.
I authorize Quality Care Options to obtain information that may be relevant to an evaluation of my educational and professional credentials, including information pertaining to disciplinary actions, criminal background, child abuse clearance, professional liability and malpractice claims, employment verification.
I understand that if I falsify, misrepresent, or omit information on this application that it may result in failure to obtain an assignment.
I authorize Quality Care Options to disclose information relating to my qualifications, ability, and character to any potential customer for the purpose of fulfilling an assignment. I also release Quality Care Options from all liability for any damages from the disclosure of this information.
I release all parties and persons from any and all liability of all damages that may result in furnishing information to Quality Care Options as well as from the use or disclosure of such information by Quality Care Options or any of its employees.
I understand if there is any change with my professional credentials, (claims pending, disciplinary actions etc) I must inform Quality Care Options as soon as possible.
I understand that if I am hired as an Independent Contractor, Quality Care Options does not guarantee any specific number of hours or shifts.

Application for Assignment