Online Application

EMPLOYER/ name, address & phone
(most recent first)

Position
Salary

DUTIES
RESPONSIBILITIES

REASON FOR LEAVING

Denver's Premier Support Staffing Service

Employment Application

(* Required fields)

* Date (mm/dd/yyyy):	Classification:

*First Name:	*Last Name:	Phone:	Cell Phone:

Permanent Address:	City:	State:	Zip:

Temporary Address:	City:	State:	Zip:

Emergency Contact:	Phone:	Relationship:

Have you ever applied with Mile High Health Team before?	Have you ever worked for Mile High Health Team before?	If yes, give dates:
Yes No	Yes No
Have you ever been convicted of a felony of crime that would affect your license or profession?	If yes, explain and give dates
Yes No
Has your nursing license ever been disciplined?	If yes, explain and give dates
Yes No
Which other states are you licensed in?	How did you hear about Mile High Health Team?

*Email Address:

EXPERIENCE

*Years of experience must add up to the total year number of years that you have worked

Other professional certifications, specialized training or forieign languages:

EDUCATION

EMPLOYMENT HISTORY

Other names under which you have been employed:

By electronically signing and submitting this online application I agree to the following:

I attest that the information on this application is true and complete. I understand that falsification of information is grounds for termination of my employment. I hereby authorize Mile High Health Team, Inc. to release any information in my employment folder to client facilities and/or their accreditation organization(s) for the purpose of accreditation, licensure or other requirements. I understand that this is employment at will.

* Application Electronic Signature: By entering your name here you are "electronically signing" this document and agree to the above statement.

Please Click the "Submit" button only once.