Clinical One - Online Application

If you would like to register with Clinical One, please give us some information about yourself. Please note that submitting this on-line application to Clinical One in no way obligates you to accept a position with the company. This first step simply allows you to be included in our database and kept up to date on current job openings. You will also then be eligible to apply for any positions that are of interest to you.


(You must have Acrobat® Reader® installed to download the PDF Application. Click here to download for free)

Fields with (*) are mandatory.
How can we help you?
Select work preference here
* Date Available To Start Working (mm/dd/yyyy):
Account Information

A valid email address is required in order to submit your application. A confidential password will be sent to the email address you provide which can be used to log back in to My Clinical One in the future.

* Email Address* Confirm Email Address:
Personal Information
Please enter your full legal name as it appears on your Social Security Card
* First Name: * Last Name:  Middle Name:
Home Phone: Work Phone: Mobile phone:
Emergency Contact Name: Relationship: Emergency Contact Phone:
Best Time to Reach You: SSN (optional): Other Name(s) / Maiden Name:
  
Address Information
Current Address:
* Street Address 1:Street Address 2:* City:
* State:* Country:* Zip/Postal Code:
Is this your Permanent Address?  Yes No
Professional Information
* Primary Profession:
 
How did you hear about us?
* Please select here:
Education Information
Technical or Nursing School:
* Professional Education / College Name: Graduation Year (yyyy):
* City: * State/Province: * Country:
* Education Type:
 
 
License/Registration Information
Original State Of Licensure:* Month/Year you passed your board/licensing exam (if applicable):
Licenses Held
License Type: License Number:
State/Province: Expiration Date (mm/dd/yyyy):
Certification Information
Certification Type: Expiration Date (mm/dd/yyyy):
 
 
Additional Information
* Have you ever had any disciplinary action taken against your professional license in any state/province? No Yes
* Have you ever plead guilty or been convicted of a misdemeanor or felony?No Yes

(Note: Please be aware that an affirmative response will not necessarily be a bar to employment. Facts such as age of conviction and rehabilitation will be considered.)

* Are you currently employed? No Yes
* Do you speak any language other than English? No Yes
Employment History
Please provide your complete employment history since passing your board of licensing exam (if applicable) or for at least the past five (5) years, beginning with your most recent employer. In the Hospital/Facility field, please list the actual name of the facility where the job duties were performed. If you were contracted for that work through an Agency, please provide this information in the Agency field.
* Hospital / Facility: * Unit Type/Specialty:
* From Date (mm/dd/yyyy): To Date (mm/dd/yyyy):* Floor Name/Number:
* City: * State: * Country:
Hospital Size (total # of beds): Teaching Hospital: Charge Experience:
* Position Title:* Status:
Unit Size (# of beds): * #Hrs / Week:* Shift:
* Supervisor's Name: * Supervisor's Title:* Supervisor's Telephone:
Additional Supervisor's Name:Additional Supervisor's Title:Additional Supervisor's Telephone:
* Position Type: Agency: Salary:
* Reason For Leaving:
Comments:
 
Skills Checklist

* Please click here to complete at least one skills checklist

Equal Employment Opportunity Data (optional)

Randstad Professionals (DBA Clinical One) is an equal opportunity/affirmative action employer in all of its employment and personnel actions.

Please complete this information to assist us in complying with equal employment opportunity record keeping and reporting requirements. Providing this information is voluntary, refusal to provide the information will not result in any adverse treatment.

   Race/Ethnic Group:
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Sex: Handicapped/Disabled:
Vietnam Era Veteran: Yes   No
Disabled Veteran: Yes  No
Other Veteran: Yes  No
Submitting Your Application
 

I hereby certify that the information submitted on this application is accurate. I understand that this application is not a contract for employment between Clinical One and the applicant for either employment or for providing of any benefit. Any offers of employment are made conditional upon the verification of information provided through this application. I understand that any falsification on this application will result in disqualification for employment or termination of services.
I understand that as a requirement of employment with Clinical One, verification of education including any degrees or certification programs and state licensure as well as criminal background screen are required for all applicants to Clinical One. I hereby authorize all previous educational institutions, certification programs, and state licensing facilities to release my information to Clinical One.
I understand that some client facilities may require drug screening and that my Recruitment Specialist will inform me of these requirements before I accept an assignment at one of these facilities.
I hereby authorize my current and previous employers to release information regarding my work performance to Clinical One. I release all such employers from any liability for issuing this information to Clinical One. I understand that I am not required to provide my social security number. I understand that if I choose to provide my social security number, it will be used in connection with the background checks described above, including verification of my state licensure.
I also hereby permit Clinical One to share this information, including my social security number (if provided), with its client facilities. I hereby release Clinical One from any and all liability arising out of such clients’ use or possession of my personal information.

I understand that by typing my name and the date below and clicking the "Submit Your Application" button on this form, it binds me to the same extent as a written signature

* [Individual's Full Legal Name] * Date (mm/dd/yyyy):
60 Harvard Mill Square * Wakefield, MA 01880 * Tel: 800.919.9100 * Fax: 877.747.9300 *  www.clinicalone.com
a Randstad company