Employment Application

Last Name Please enter last name.
First Name Please enter first name.
Middle Name Please enter middle name or initial.
Maiden Name

Address/Contact Info

Main Phone Number Please enter phone number. Please enter phone with area code.
Second Phone Number
Email Address Please enter email address.Please enter valid email address.

Position Applied For Please enter position(s) you are applying for.

If you have a professional license (LVN, RM) please include your license number below
Professional License Number

I understand this is a PRN position (Please Check)

How Many Hours Would You Like to Work Weekly? A value is required.
Can You Work Nights? Please tell us if you can work nights.
Can You Work Weekends? Please tell us if you can work weekends.
When Are You Available to Start?

Please state any schedule limitations or preferences such as "Not available Tuesdays", or "Prefer off by 6pm weekdays". Be as detailed as you wish.

Name
Phone

Please check the skills you have on the list below.

Vent
Trach
Phlebotomy
IV Certfied
G-Tubes
ERM(Electronic records management)

If you have experience with any ERM programs, such as electronic hospice charting, please list programs below:

Please list your work experience for the last five years beginning with your most recent job. There are spaces or three employers below. If you have had more than three employers the last three years, please bring that information with you if requested to come for an interview. If you do want us to contact a current or former employer at this time please check "No" when asked below.

Most recent or current employer:

Employer Name Please enter your prior employer's name
May we contact this employer before we interview you?
Yes
No, do not contact yet

Dates Employed: Start: Enter most recent employment start date
Dates Employed: End: Enter most recent employment end date.
Address, City, State Zip Code A value is required.
Supervisor  A value is required.
Last Job Title A value is required.
Work Phone  A value is required.
Duties/responsibilities:
A value is required.
Starting Pay A value is required.
Ending pay: A value is required.
Reason for Leaving (Be specific)
Required.
List jobs held, duties, skills used or learned, advancement or promotions while employed here
Required.

Employer 2.

Employer Name
May we contact this employer before we interview you?
Yes
No, do not contact yet

Dates Employed: Start: End:
Address, City, State Zip Code
Supervisor 
Last Job Title
Work Phone 
Duties/responsibilities:

Starting Pay
Ending pay:
Reason for Leaving (Be specific)

List jobs held, duties, skills used or learned, advancement or promotions while employed here

Employer 3. 

Employer Name
May we contact this employer before we interview you?
Yes
No, do not contact yet

Dates Employed: Start: End:
Address, City, State Zip Code
Supervisor 
Last Job Title
Work Phone 
Duties/responsibilities:

Starting Pay
Ending pay:
Reason for Leaving (Be specific)

List jobs held, duties, skills used or learned, advancement or promotions while employed here

Have you ever been in the armed forces?
Yes
No

Are you now a member of the National Guard?
Yes
No

Specialty
Date Entered Discharge Date

High School Name
Address
Number Years Completed
Main Line of Study
Did You Graduate?

College Name
Address
Number Years Completed
Major/Degree
Did You Graduate?

Trade School Name
Address
Number Years Completed
Major/Degree
Did You Graduate?

Professional School Name
Address
Number Years Completed
Major/Degree
Did You Graduate?

During the past 5 years, have you been convicted of, or have you pled guilty or no contest to, a felony or misdemeanor offense other than minor traffic tickets? If yes, please explain in the space below. (Answering "yes" to this question will not automatically bar you from employment unless applicable law requires such action.

No
Yes
Please make a selection
If Yes, explain number of conviction(s), nature of offence(s), dates of offence(s), sentence(s), and type(s) of rehabilitation

Birth Date (month and day only) This is required and is only used to assure accurate background/license checks. We do not need the year as we are not verifying age.

Birth Month: January February March April May June July August September October November December Birth Day: 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Do you have a drivers license
Yes
No Please make a selection

Number of accidents last three years
Number of moving violations last three years

Will your car be your means of transportation to work?
If not, how will you get to work?

Please list two references other than relatives or previous employers

Name
Relationship
Address
Phone

Name
Relationship
Address
Phone

An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the space below to summarize any additional information you wish to add to describe your full qualifications for the specific position for which you are applying.

By clicking "Submit" I give Expedient Medical Staffing permission to do a reference check on me, which may involve contacting contacting current or past employers, except for those which I selected: "No do not contact yet", above. I also certify that I have fully and accurately answered all questions and have given all information requested in this application for employment, and I understand that any wrong or incomplete information on the form may disqualify me for further consideration for employment or, if discovered after I am hired, may be grounds for my immediate dismissal. I understand that all such information is subject to verification by the Company, and hereby give my consent to the Company to investigate my background and qualifications using any means, sources, and outside investigators at its disposal. I agree to undergo any type of drug and/or alcohol testing that the Company may require at any time. Finally, I understand that submission of this application does not necessarily mean that I will be hired, and that if I am hired, my employment will be at will, and either I or the Company may terminate my employment at any time, with or without notice or reason.

If you click "Submit" and you are not redirected to a "Thank You" confirmation page, please scroll back to the top of the application and check for missing or incorrectly formatted field notices in red. Complete those fields click Submit again.