[**COVID-19: Learn about our Safe Care plan and important updates**.](https://baylorfrisco.com/covid-19)
[**COVID-19: Learn about our Safe Care plan and important updates**.](https://baylorfrisco.com/covid-19)
5601 Warren Parkway
Frisco, TX
75034
,
United States
855.437.4726
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Please list certification/licensure, accrediting organization, expiration date and professional membership in each line.
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Professional Credential/Affiliate 3
Has your license (in any jurisdiction that you may have been licensed in) ever been investigated, suspended, or revoked?
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No
If yes, please detail the circumstances and the final outcome. (An affirmative answer will not disqualify you from being considered as a candidate for employment.
Health Care Specialty
Please list area and years of experience for each health care specialty.
Health Care Specialty 1
Health Care Specialty 2
Health Care Specialty 3
Health Care Specialty 4
Health Care Specialty 5
Please indicate which of the following credentials you currently hold
CPR
ACLS
PALS
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CEN
Other
IV Therapy Course
OCN
CNOR
CRRN
EKG Course
Critical Care Course
Other Courses
Please list any other education, training, special skills, or certificates/licenses that you possess that are related to this position.
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General Information
List any foreign languagues you speak fluently, please include if you read, write or speak this language.
Foreign Language 2
Foreign Language 3
Do you have Military Experience
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If yes, what branch, dates of service, and rank
Can you, upon employment, submit verification of your legal right to work permanently in the United States?
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Are you 16 years of age or over?
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If you are under 18, please list your age
Have you ever been convicted of a felony, or pleaded no contest to a felony, or been convicted of a misdemeanor resulting in imprisonment or a fine over $500 in the last ten years? (criminal convictions are not an automatic bar to employment but will only be considered in relation to specific job requirements.
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No
If yes, please explain
Do you require any accommodation to perform the essential functions of this job?
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If yes, please explain
If you are presently employed, may we contact your employer?
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Have you ever been employed by Baylor Frisco, USPI or any of its affiliated companies?
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If yes, please list facility, dates of employment, and name you were employed under
Are you currently or have you previously been excluded, suspended, or otherwise been ineligible for participation in federal programs, or do you have a controlling interest in an entity that has been so excluded or suspended? Have you ever been sanctioned, disciplined, debarred, and/or excluded by a duly authorized agency, or are there current restrictions/limits on your license or certification?
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Have you held jobs in the past ten year other than those listed on this application?
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Have you ever been terminated from a job or resigned from a job as an alternative to termination?
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Have you ever been disciplined or warned by an employer for excessive absence, lateness, or poor job performance?
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No
If yes, please explain
Are you currently under an employment contract?
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No
If yes, when does it expire?
Do you currently have any relative(s) or persons with whom you are involved in a close personal relationship employed by Baylor Frisco or USPI?
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If yes, please list
Employment History
Name of Company/Organization and Industry (1)
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Start and End Date
Job Title
Reason for Leaving
Your Name when Employed
Supervisor Name and Telephone Number
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Name of Company/Organization and Industry (3)
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Reason for Leaving
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Name of Company/Organization and Industry (4)
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Reason for Leaving
Your Name When Employed
Supervisor Name and Telephone
Please give explanation of any lapses in employment dates above:
Professional References
List three individuals - minimum of two supervisory references. 3 references are required for application.
REFERENCE 1
First
Last
Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Occupation
Phone Number
REFERENCE 2
First
Last
Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Occupation
Phone Number
REFERENCE 3
First
Last
Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Occupation
Phone Number
AGREEMENT
By signing below, I certify that the information I have provided on this application is true and correct to the best of my knowledge, and I understand that any misrepresentation or willful omission of facts shall be cause for rejection of this application or termination. I also certify that I have read, understand, and authorize any person, agency, or other entity contacted by Baylor Scott & White Medical Center - Frisco or its agents to furnish the information listed below. I hereby authorize Baylor Scott & White Medical Center - Frisco to conduct work history, education, personal reference or police record inquiries to determine my acceptability for employment. I authorize Baylor Scott & White Medical Center - Frisco and its agents to procure a consumer report and/or investigate consumer report about my background, character or reputation, including but not limited to information as to my employment, education, consumer credit history (if appropriate for certain job descriptions), driving record, social security number verification, criminal record, and/or other public record history. I authorize all persons to fully disclose information relevant to this investigation. I release from liability all persons, companies, and government or other agencies disclosing such information. If further authorize a photocopy of this authorization to be considered an original. I understand that this employer agrees that it will provide workers' compensation insurance coverage for its employees. In the event of an injury in the workplace, I agree that my sole remedy lies in coverage under this employer's workers' compensation insurance policy. I understand, and agree that as a condition of employment, I will be required to submit to an employment physical examination and a drug screen, and other physical examinations consistent with law during my employment at Baylor Scott & White Medical Center - Frisco. I may, at the discretion of Baylor Scott & White Medical Center - Frisco be required to submit to a drug screen upon request during my employment. I further agree, if employed, to observe all rules, regulations and policies of Baylor Scott & White Medical Center - Frisco. Additionally, I comprehend Baylor Scott & White Medical Center - Frisco commitment to its Code of Conduct, Compliance Plan and anti-harassment policies and further agree, if employed, to carefully review and abide by these policies. If I am employed at Baylor Scott & White Medical Center - Frisco, I understand that my employment can be terminated without cause and without notice, at any time, at the option of Baylor Scott & White Medical Center - Frisco.
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