HEALTHCARE STAFFING AGENCY

Employment
application.

Complete all applicable sections. Fields marked with * are required.

3415 Periwinkle Way
Edgewood, MD 21040
(443) 248-1162
impactcareservicesinc@gmail.com

Equal Employment Opportunity: This agency provides equal employment opportunities to qualified applicants without unlawful discrimination and in accordance with applicable federal and state laws.

Jump to a sectionYour details Availability Eligibility Credentials Education Experience Work history References Disclosures Screening Emergency contact Sign application 1099 acknowledgment

AVAILABILITY

When can you work?

Select at least one available day and shift. *

Are you available for weekends? *

Yes No

Are you available for holidays? *

Yes No

Are you available for overtime? *

Yes No

Are you available for short-notice assignments? *

Yes No

EDUCATION & TRAINING

Education history.

Answer the diploma/GED question. If Yes, include the school or program and its location. Other education is optional where not applicable.

High School/GED

School City/State

Diploma/GED received? *

Yes No

College/University

Institution Degree/Major Graduation Date

Nursing/Healthcare Training Program

School/Program Program Completed Completion Date

Other Relevant Training

EMPLOYMENT HISTORY

Your recent work history.

Begin with your most recent employer. If you have work history, complete the first employer. Complete essential details for any additional employer you enter. Leave the end month blank for a current job and enter “Currently employed” as the reason.

Do you have previous or current employment to list? *

Yes No

Employer #1

Employer Address Phone Position Supervisor

From To

Reason for Leaving

May we contact this employer?

Yes No

Employer #2

Employer Address Phone Position Supervisor

From To

Reason for Leaving

May we contact this employer?

Yes No

Employer #3

Employer Address Phone Position Supervisor

From To

Reason for Leaving

May we contact this employer?

Yes No

PROFESSIONAL REFERENCES

People who can verify your work.

Provide at least one reference with a name, relationship and phone or email. A supervisor, instructor or volunteer coordinator may be used if you are new to healthcare. Complete these details for each additional reference you enter.

Reference #1

Name Relationship/Position Company Phone Email

Reference #2

Name Relationship/Position Company Phone Email

Reference #3

Name Relationship/Position Company Phone Email

PROFESSIONAL & EMPLOYMENT DISCLOSURES

Job-related disclosures.

Where permitted by applicable law. An affirmative response does not automatically disqualify an applicant; information will be evaluated under applicable law and position requirements.

Have you ever had a professional license or certification suspended, revoked, restricted, placed on probation, or otherwise disciplined? *

Yes No

If yes, explain

Are there currently any restrictions on your professional license or certification? *

Yes No

If yes, explain

Have you ever been terminated or asked to resign from a healthcare position because of alleged misconduct, abuse, neglect, exploitation, patient safety concerns, diversion, or violation of professional standards? *

Yes No

If yes, explain

BACKGROUND & SCREENING ACKNOWLEDGMENT

Pre-employment requirements.

I understand that employment or placement may be contingent upon successfully completing applicable pre-employment requirements, which may include:

Criminal background screening
Professional license/certification verification
Employment verification
Professional reference checks
Exclusion/sanction screening, when applicable
Drug screening, when required
Health screening and required immunization documentation
TB screening/testing, when applicable
CPR/BLS verification
Competency assessment
Orientation and mandatory training
Other screening required by law, regulation, facility, payer, or contractual requirements

I understand that separate authorization and disclosure forms may be required for certain background investigations and screenings.

Applicant Initials *

EMERGENCY CONTACT

Who should we contact?

Name *Relationship *Phone *Alternate Phone

APPLICANT CERTIFICATION & AUTHORIZATION

Certify your application.

I certify that the information provided in this application is true, accurate, and complete to the best of my knowledge.

I understand that any material false statement, omission, or misrepresentation may result in disqualification from consideration or, if discovered after employment, may result in disciplinary action up to and including termination, subject to applicable law.

I authorize the agency to verify information concerning my education, professional credentials, employment history, references, and other job-related qualifications, subject to applicable federal and state requirements.

I understand that submitting this application does not constitute an employment contract or guarantee employment, hours, assignments, shifts, or placement at any particular healthcare facility.

I understand that, if employed, I am responsible for maintaining all licenses, certifications, credentials, and training required for my position and immediately notifying the agency of any suspension, expiration, restriction, investigation, or other change affecting my eligibility to perform assigned duties.

Applicant Name (Print) *Applicant Signature (Type Full Name) *Date *

INDEPENDENT CONTRACTOR (1099) ACKNOWLEDGMENT

Review the contractor terms.

This acknowledgment does not override the actual nature of a working relationship or applicable law.

1. Independent Contractor Status

I understand and acknowledge that I am being engaged by Impact Care Services Inc. as an independent contractor, subject to the actual nature of the working relationship and applicable federal and Maryland law.

I understand that this agreement is not intended to create an employer-employee relationship where the circumstances and applicable law establish otherwise.

2. Form 1099-NEC Acknowledgment

I understand that compensation paid to me for services performed as an independent contractor will be reported by Impact Care Services Inc. to the Internal Revenue Service and other applicable taxing authorities on Form 1099-NEC, when reporting is required by law.

I acknowledge that I am responsible for providing Impact Care Services Inc. with accurate taxpayer information, including completing Form W-9 when requested.

3. Tax Responsibility

As an independent contractor, I understand that Impact Care Services Inc. generally will not withhold federal income tax, Maryland income tax, Social Security tax, or Medicare tax from payments made to me, except where withholding is required by law.

I understand that I am responsible for reporting taxable income; paying applicable federal, state, local, and self-employment taxes; making estimated tax payments when required; and maintaining appropriate tax and business records.

4. No Employee Benefits

I understand that, as an independent contractor, I am not automatically entitled to employee benefits from Impact Care Services Inc., including paid vacation, paid sick leave, health insurance, retirement benefits, unemployment benefits, or other employee benefits, except to the extent otherwise required by applicable law.

5. Contractor Responsibilities

I agree to perform all accepted assignments professionally and in accordance with applicable laws, regulations, client requirements, confidentiality requirements, and Impact Care Services Inc. policies that lawfully apply to contracted services.

I understand that I am responsible for maintaining any license, certification, training, insurance, or other qualification legally required to perform the services for which I am contracted.

6. Acknowledgment

By signing below, I acknowledge that Impact Care Services Inc., 3415 Periwinkle Way, Edgewood, MD 21040, has informed me that I am being engaged as an independent contractor and that I will receive a Form 1099-NEC for compensation paid to me when required by applicable tax law.

I acknowledge that I have read and understand this form and have had an opportunity to ask questions before signing.

Contractor/Applicant Name (Print) *Contractor Signature (Type Full Name) *Date *

FOR AGENCY USE ONLY

Internal review.

Completed by Impact Care Services Inc. after submission.

Application ReceivedInterview DatePositionLicense VerifiedCertification VerifiedReferences CompletedBackground ScreeningDrug ScreeningHealth/TB DocumentationCompetency AssessmentOrientation CompletedApproved for PlacementApproved PositionApproved BySignatureDateNotes

By submitting, you confirm that the electronic signatures above are yours.

Day	Day Shift	Evening Shift	Night Shift	Any Shift
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Employment
application.

Tell us about yourself.

When can you work?

Eligibility and transportation.

Professional credentials.

Primary License/Certification

Additional License/Certification

Education history.

High School/GED

College/University

Nursing/Healthcare Training Program

Experience and clinical skills.

Your recent work history.

Employer #1

Employer #2

Employer #3

People who can verify your work.

Reference #1

Reference #2

Reference #3

Job-related disclosures.

Pre-employment requirements.

Who should we contact?

Certify your application.

Review the contractor terms.

1. Independent Contractor Status

2. Form 1099-NEC Acknowledgment

3. Tax Responsibility

4. No Employee Benefits

5. Contractor Responsibilities

6. Acknowledgment

Internal review.

Employmentapplication.

Tell us about yourself.

When can you work?

Eligibility and transportation.

Professional credentials.

Primary License/Certification

Additional License/Certification

Education history.

High School/GED

College/University

Nursing/Healthcare Training Program

Experience and clinical skills.

Your recent work history.

Employer #1

Employer #2

Employer #3

People who can verify your work.

Reference #1

Reference #2

Reference #3

Job-related disclosures.

Pre-employment requirements.

Who should we contact?

Certify your application.

Review the contractor terms.

1. Independent Contractor Status

2. Form 1099-NEC Acknowledgment

3. Tax Responsibility

4. No Employee Benefits

5. Contractor Responsibilities

6. Acknowledgment

Internal review.

Employment
application.