Name *

Date*

Other name used in employment:

Position Desired:

State License #:

Expiration Date:

Street Address *

Home Phone *

Business Phone:

City: *

State *

Zip Code *

Available:

Full Time

Part Time

Contract

Shifts willing to work:

Day

Evening

Weekend

Are you legally eligible to work in the U.S.A?

Yes

No

If on a visa, what type?

Social Security #:

Driver's License #

Expiration Dates:

Health Card:

CPR Card

ACLS Certification Date:

Have you ever been convicted of a crime?

Yes

No

Conviction of a crime is not an automatic bar to employment, other factors such as the nature and date of the crime will be taken into consideration

Yes

No

Employer & Full Address Last or Current Position

Type of Business

Position Held

Position

Superior & Title

Work Phone

Starting Pay

Final Pay

Reason for Job Change

Describe Duties/Responsibilities

Employer & Full Address Last or Current Position

Type of Business

Position Held

Position

Superior & Title

Work Phone

Starting Pay

Final Pay

Reason for Job Change

Describe Duties/Responsibilities

Employer & Full Address Last or Current Position

Type of Business

Position Held

Position

Superior & Title

Work Phone

Starting Pay

Final Pay

Reason for Job Change

Describe Duties/Responsibilities

I certify that the information on this application is correct and I understand that any misrepresentation or omission of any information will result in my disqualification from consideration for employment or, if employed, my dismissal, I understand that this is not a contract, offer, or promise of employment and that if hired, I can be terminated at will, with or without cause, with or without notice, at any time and for any reason, at the option of either Absolute Care Staffing Health Agency or myself. I further understand that no supervisor, manager, official of representative Absolute Care Staffing Health Agency and its related entities has the authority to enter into an employment contract or make any agreement, orally or in writing, contrary to the forgiving. I have read, understand, and agree to this statement (please initial here). Absolute Care Staffing Health Agency in considering my application for employment may verify the information set forth on this application, related papers or oral interviews and obtains additional background information relating to my background. I authorize all persons, schools, companies, corporations, law enforcement agencies and doctors to supply any information concerning my background that they may have whether or not it is on their records. I hereby release them and their company from all liability for divulging same. A photographic copy of this authorization shall be as valid as the original. If any of my given information is found to be false or misleading. I understand that I will be subject to dismissal at any time during the period of my employment without liability for wages or salary except such as may have been earned at date of such termination and I agree to hold Absolute Care Staffing Health Agency and persons named herein blameless in that event. I have read, understand and agree to this statement (please initial here). Absolute Care Staffing Health Agency is an equal opportunity employer and does not discriminate in its recruiting, selecting and hiring procedures because of race, color, gender, religion, national origin, age, sexual orientation or disability status nor does it discriminate with regard to Veteran status.