Job Application APPLICATION FOR EMPLOYMENT Thank you for applying for a position at Holistic Medical Staffing. Kindly fill out this form and indicate the position (s) you would like to be considered. Name First Middle Last Date of birth_ Social Security Phone number Email Address Present Address: Mailing Address: __ Emergency Contact: phone number Employment Position desired: If hired, on what date can you start work? EDUCATION AND TRAINING Degree Obtained. Date Graduated High School _ College/University Vocational/Business EMPLOYMENT HISTORY List below all past and present employment, starting with your most recent employer: Are you currently employed? YES NO May we contact your present employer? YES NO Name of Employer: First Last Address Telephone Your supervisor’s Name: First Last Position Held: Date of Employment: Exact reason for leaving : LICENSE INFORMATION Answer the following questions if applying for a professional position Are you licensed for the job apply for?: YES NO Type of license RN LPN CNA Issuing state License/Certification number: Has your license ever lapsed being revoked or suspended? YES NO If yes state reason(s), date of lapsed, revocation or suspension and date of reinstallment: Have you ever under your name or another name being convicted of (or pleaded guilty or nolo contendere to) a felony or misdemeanor? YES NO Have you ever under your name or another name being convicted of a crime, which resulted with your being in prison and released from prison or paroled? YES NO Are you currently under arrest or released on bond or your own recognizance pending trial for a criminal offense? YES NO If yes, state the nature of the crime charged and when and where trial is pending: AUTHORIZATION Personally completed this form honestly and accurately By my signature below, I promise that I have personally completed this application. I declare under penalty of perjury that the information provided in this employment application ( and accompanying resume), if any is true and complete, And I understand that any false information or significant omissions may disqualify me from further consideration for employment, and may be justification for my dismissal from employment if discovered at a later date. I understand that any job offer is conditional based on the satisfactory review of my qualifications, including any and all background or drug screening which may be disqualified. Drug and alcohol screening. I give permission for a pre employment drug/ alcohol screening exam, and, If the company makes a conditional job offer, I give permission for a complete employment, physical and mental examination. I also consent to the appropriate release of any and all medical information, as may be deemed necessary. Authorization to obtain information. I voluntarily and knowingly authorize any present or past employer. Common supervisor, administrator, educational institution, law enforcement agency, state, local, or federal agency., Credit Bureau, Collection Agency, Private Business, Military Branch, The National Personnel Records Center, Personal Reference, and all other persons., to give records or information they may have concerning my criminal history, motor vehicle reports, educational history, licensing, employment including character, earnings history and reasons for termination or any other information requested by the company requested to determine my eligibility for employment. Release I voluntarily waive all recourse and release any company, individual or organization from that liability for complying with any request from the company or agents of the company, including any consumer reporting agency, to obtain any information from any source whatsoever relating to my application for employment. I further released the company or any individual within the company regarding the use of any information received, which may have bearing on my application for employment. Notification and compliance with rules I agree to immediately notify the company if I should be convicted of a crime Why my job application is pending, or during my employment if hired. If I become Employed, in consideration of my employment, I agreed to comply with the rules, regulations, policies and procedures of the company. I certify that all the information I provided on this application is true and accurate. MEDICAL RELEASE Any false or misleading statements will also result in the offer being rescinded. It is important. That this form is accurate and complete to ensure the timely processing of this personal and medical information. Rest assured that your information will be handled confidentially and in compliance with the American with Disabilities Act. REQUEST FOR EMPLOYMENT VERIFICATION we will also need copies of the following documents to finalize your employee record. Driver’s License And SS Card. Select File(s) Select File Current License Select File(s) Select File Current ACLS/PALS/NRP Select File(s) Select File Copy Of Immunization Record (Proof Of MMR) Select File(s) Select File Copy Of TB (PPD Skin Test) Within One Year. Select File(s) Select File Urine Drug Screen Panel Select File(s) Select File Copy of Resume Select File(s) Select File Others Select File(s) Select File
