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Instructions  Please be as thorough as possible in each of your answers. We strongly encourage you to complete each field as we will be better able to determine your fit with our organization. If a question does not apply to you, please use N/A (Not Applicable).

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APPLICANT CERTIFICATION & AGREEMENT: (Read carefully before signing)
I certify that this information contains no willful misrepresentation or falsification and that the information given by me is true and complete to the best of my knowledge and belief. I understand that if employed, misleading or falsified statements on this application may be considered cause for dismissal. I hereby authorize Coastal Healthcare Resources, its affiliates and successors, to obtain any information that may be relevant to an evaluation of my professional qualifications for privileging, including information pertaining to disciplinary actions, criminal background, drug screen results, education, work history, or other confidential or privileged information, and other credential documents.
I authorize Coastal Healthcare Resources to disclose to current, prior, or potential contractors making a reasonable inquiry, information relating to my qualifications, ability, and character.
Only to the extent requested and required by the practices, facilities, groups and hospitals staffed or managed by Coastal Healthcare Resources where I will be providing clinical services, I agree to provide and authorize the release of the same by Coastal Healthcare Resources to Coastal Healthcare Resources clients, the following: a) vaccination records; b) reasonable documentation evidencing that I am in good health and free of communicable diseases; c) the result of and/or a copy of my criminal background check, if any and d) the result of and/or a copy of my drug screen, if any.
I hereby release Coastal Healthcare Resources, its officers, employees, and agents, and third parties which provide or receive information regarding my credentials, including, but not limited to, all credentialing information sources, individuals or companies who provide references, companies or agencies that perform clinical background checks, and companies that perform drug screens, from any claims, causes of action, damages and expenses, including reasonable attorney’s fees arising from or relating to the collection, verification, an dissemination of my credentialing and other information.
I agree to hold Coastal Healthcare Resources harmless from and against any and all claims, causes of action, damages, judgments and expenses, including reasonable attorney’s fees, arising from or related to the accuracy of the information provided by me. I understand that this does not contemplate a duty to hold Coastal Healthcare Resources harmless from claims, causes of action and damages which may arise as a result of information provided about me from sources other than me.
This is a continuing authorization and shall be effective from the date of signature below until such time as I have specifically revoked the same in writing.
If any material changes occur affecting my professional status, it is my obligation to notify Coastal Healthcare Resources or the appropriate affiliate or successor as soon as possible. I understated that the decision to subcontract with me or refer me to practice opportunities is solely at the discretion of Coastal Healthcare Resources.
I understand that any information received from references is confidential and may not be released to me without the consent of the reference. I understand, agree and acknowledge that references are not part of my personnel file.
A copy or facsimile of this document shall have the same effect as the original.
This document shall be interpreted according to the laws of the state of South Carolina.

Enter your name in the text box below to sign your application and agree to these terms.
Equal Employment Opportunity
We are an Equal Opportunity employer and do not discriminate on the basis of race, ancestry, color, religion, sex, age, marital status, sexual orientation, national origin, medical condition, disability, veteran status, or any other basis protected by law.

The Information provided will be used for research, reporting, statistical purposes and to monitor legal compliance. To help us comply with these government requirements, please complete the following information.

Completion of this form is voluntary and will not affect your opportunity for employment or terms or conditions of employment if hired. We appreciate your cooperation.

Gender




Ethnicity

Race (do not respond if you selected "Hispanic or Latino" above)
A person having origins in any of the original peoples of Europe, the Middle East, or North Africa
A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam
A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment
A person having origins in any of the black racial groups of Africa
A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands
A all persons who identify with more than one of the above five races

Protected Veterans
The definitions of protected veterans are listed below. Use the boxes following the definitions to indicate whether you are a protected veteran
Disabled Veteran
A "disabled veteran" is one of the following:

A veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or

A person who was discharged or released from active duty because of a service-connected disability.
Recently Separated Veteran
A "recently separated veteran" means any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service.
Active Duty Wartime or Campaign Badge Veteran
An "active duty wartime or campaign badge veteran" means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.
Armed Forces Service Medal Veteran
An "armed forces service medal veteran" means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.

Disability Status
You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.


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