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APPLICATION FOR EMPLOYMENT (1)

APPLICATION FOR EMPLOYMENT (1)

Address
Address
City
State/Province
Zip/Postal
Are you a US citizen? *
you are not a US citizen 1. are you a permanent resident of the U.S.?
you are not a US citizen 2. are you authorized to work in the U.S. on an unrestricted basis?
(You will be required to provide documentation if you are invited for an interview.)
* Do you use any tobacco products, including nicotine replacements?
(Perfusion Partners) is not able to hire nicotine and tobacco product users. Nicotine testing is part of the pre-employment process.)

EDUCATION

EDUCATION

Address
Address
City
State/Province
Zip/Postal
Country

Maximum file size: 15MB

COLLEGE

Address
Address
City
State/Province
Zip/Postal
Country

Maximum file size: 15MB

GRADUATE / OTHER

Address
Address
City
State/Province
Zip/Postal
Country

Maximum file size: 15MB

GRADUATE / OTHER

Address
Address
City
State/Province
Zip/Postal
Country

Maximum file size: 15MB

CLINICAL EDUCATIONAL ROTATIONS

(If Less than Three (3) Years from Graduating from Perfusion School)
Are you certified by the ABCP?

Maximum file size: 5MB

Maximum file size: 5MB

If not certified by ABCP, did you graduate from an accredited Perfusion Training Program?
Are you currently or have you at any time been licensed as a Perfusionist by any state?
Have you ever had any professional license or certification at any state or national level that has ever been denied, limited, suspended, sanctioned, revoked, probated, voluntarily or involuntarily relinquished or not renewed?
Have your employment, medical staff appointment, or clinical privileges ever been voluntarily or involuntarily surrendered or not renewed on either a temporary or permanent basis?

EMPLOYMENT EXPERIENCE

Currently Employed?
Address
Address
City
State/Province
Zip/Postal
May we contact?

EMPLOYMENT EXPERIENCE

Currently Employed?
Address
Address
City
State/Province
Zip/Postal
May we contact?

EMPLOYMENT EXPERIENCE

Currently Employed?
Address
Address
City
State/Province
Zip/Postal
May we contact?

PROFESSIONAL REFERENCES

Please provide the names of three professional references that you have worked with in the past 4 years, ONE REFERENCE MUST BE A PHYSICIAN.

Reference 1 (Peer)

Month/Day/Year - Month/Day/Year
Address
Address
City
State/Province
Zip/Postal
Country

Reference 2 (Peer)

Month(2020) - Month(2021),
Business Type and Name
Address
Address
City
State/Province
Zip/Postal
Country

Reference 3 (Surgeon or Anesthesiologist)

Month(2020) - Month(2021),
Business Type and Name
Address
Address
City
State/Province
Zip/Postal
Country
Have you ever been convicted of or been found guilty, entered a guilty plea, or entered a plea of no contest to any felony or misdemeanor?
If you answered "yes" to the question above, please describe the details including nature, circumstances, and the date of the offense. Details of minor traffic violations (i.e. speeding tickets) do not need to be provided. A conviction will not necessarily be a bar to employment.
Have you ever been dismissed from either an employment position or educational program?

Qualified applicants are considered for and treated during employment without regard to race, color, religion, national origin, citizenship, age, marital status, ancestry, physical or mental disability, medical condition, veteran status or sexual orientation.

Consent and Release Statement of Applicant

I certify that all of the information furnished in this employment application and/or additional documents are true and complete to the best of my knowledge. I understand that my stated pre-employment qualifications are subject to verification and I hereby authorize Perfusion Partners, Perfusion Consultants, and Hospital Affiliates to confirm or examine any information provided. Furthermore, I authorize any person, firm, entity or organization to supply any information about me concerning any past employment, military status, convictions or other information to Perfusion Partners, Perfusion Consultants, and Hospital Affiliates and I further release any such person, firm, entity or organization from any responsibility in disclosing such information, including all liability from damage that may result from furnishing such information. I also authorize each of my former employers, educational institutions, organizations, and references listed herein to give Perfusion Partners, Perfusion Consultants, and Hospital Affiliates any and all information concerning my education, previous employment, military status, convictions or other pertinent information they may have regarding me. I further release any such person, firm, or organization from any responsibility in disclosing such information, including all liability that may result from furnishing such information to Perfusion Partners. Perfusion Consultants, and Hospital Affiliates.  I authorize Perfusion Partners, Perfusion Consultants, and Hospital Affiliates to obtain information regarding my record with the Bureau of Motor Vehicles if the position for which I am applying involves or requires driving.

I understand that providing any false information or omitting any material information on my application materials or in the interview process will be sufficient grounds for rejection of the application, or termination of employment whenever discovered. I understand that any offer of employment may be conditioned upon the results of examinations, physical or other, as may be necessarily required by Perfusion Partners, Perfusion Consultants, and Hospital Affiliates, and/or each respective hospital of service.  Each hospital as well as Perfusion Partners, Perfusion Consultants, and Hospital Affiliates is a drug-free workplace. Individuals offered employment at Perfusion Partners, Perfusion Consultants, and Hospital Affiliates may be required to successfully complete a pre-employment physical, which includes drug testing as a condition of employment. Individuals who refuse to take or who fail the drug test, after being informed, will be removed from employment consideration. Perfusion Partners, Perfusion Consultants, and Hospital Affiliates are required by federal law to verify the identity and work authorization of all new employees. Accordingly, offers are contingent upon verification of identity and eligibility to be employed in the United States. I understand that, if hired, I may commonly access or come in contact with information considered restricted or protected by hospital or medical center policy or local, state or federal law. I understand that I must comply with HIPAA laws as it is applied to patient care information.  I further understand that mishandling or improper use of restricted information may lead to disciplinary action up to and including termination of employment or legal action.

I also understand that employment is conditional upon successfully completing the Allied Health Staff credentialing application at any respective hospital.

Employee Form