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Insurance Information Nursing Careers

    (List Institution Name and Location)


    Currently Working on a Degree/Program :

    JOB SKILLS: Please provide any additional information that you think would be helpful in our evaluation of your
    job application. Include specialized training, seminars, workshops, accreditations, special achievements or
    valuable skills:



    Please list the most recent work experience.  Describe all traditional, military and voluntary work
    experience.  Describe your knowledge, skills and abilities that demonstrate your qualifications for the position
    for which you are applying.

    Duties :

    Duties :

    Duties :

    LICENSES: (Include Driver’s License or Certifications to Practice a Trade or Profession.)



    Please list full names, addresses, phone numbers and relationship of three (3) persons

    Full NameAddressPhone NumberRelationship

    If yes, please provide the following:

    If yes, please provide Company names and details :


    I hereby certify that all entries on this job application and any attachments are true and complete.  I also agree and understand that any falsification of this information may result in my forfeiture of employment.

    Physicians PremiER Management Services, LLC, Coastal ER I, LLC, Coastal ER II, LLC, Coastal ER III, LLC, Coastal ER IV, LLC, Coastal ER V, LLC, Coastal ER VII, LLC, Coastal ER VIII, LLC, Coastal ER IX, LLC and Brazos Valley ER, LLC dba Physicians PremiER are equal opportunity employers. We do not discriminate in employment on account of race, color, religion, national origin, citizenship status, ancestry, age, sex (including sexual harassment), sexual orientation, marital status, physical or mental disability, military status or unfavorable discharge from military service.

    I understand and agree that my employment is at‐will and can be terminated with or without cause and with or without notice at any time at the option of either me or the Company. I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for Company to hire me.

    I understand that all information on this job application is subject to verification and I consent to criminal history and background checks.  I also agree that you may contact references and educational institutions listed on this application.

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