Application for Employment - Advance Medical Staffing

Step 1 of 4

25%

General Information
Name*
First Middle Last
Date:*
Temporary/Permanent:
Email:*
Social Security #:
Referred By:
Permanent Address*
Street Address Address Line 2 City State ZIP Code
Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

If different from your permanent address*
Home Number:*
In case of Emergency:*
Work Phone
Contact Phone 1:
Pager/Beeper
Contact Phone 2:
Mobile Phone:
Are you presently employed? May we contact your previous employer
Education & Training
College/University
First
Degree Received:
City:
State:
Date Received
College/University
First
Degree Received:
City:
State:
Date Received

Employment History 1
Employer:
Employment Start Date:
Employment End Date:
Position/Title:
Salary
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Supervisor:
Unit/Floor:
Telephone:
Reason For leaving:
Employment History 2
Employer:
Employment Start Date:
Employment End Date:
Position/Title:
Salary
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Supervisor:
Unit/Floor:
Telephone:
Reason For leaving:
Employment History 3
Employer:
Employment Start Date:
Employment End Date:
Position/Title:
Salary
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Supervisor:
Unit/Floor:
Telephone:
Reason For leaving:

Military Experience
Complete if you served in the United States Armed Forces.
Branch of Service:
Enlistment Date
End Time of Service (ETS)
Discharge other than Honorable
- Yes
- No
If Yes, Explain:
Describe your duties and special training:
[Disclosure of dishonorable or general discharge will not necessarily disqualify application or termination after employment.]

Background
Have you ever been convicted of a crime (misdemeanor or felony) other than a minor traffic violation, within the past seven (7) years? A conviction includes a plea, verdict, or finding of guilt regardless of whether sentence is imposed by the court.
If Yes:
Where:
When:
Charge:
Sentence:
(Disclosure of a criminal record will not necessarily disqualify you for employment; however, failure to disclose such information may result in disqualification of your application or termination after employment.)
Do you have a driver's license?:*
- Yes
- No
Driver's License No.*
State Issued:*
Expiration Date:*
Has your Driver's License ever been suspended or revoked?*
- Yes
- No
If Yes, Provide Details:
Have you been cited for a traffic violation of any kind in the past five years?*
- Yes
- No
IMPORTANT: PLEASE READ CAREFULLY
I certify that, to the best of my knowledge, all the information provided to Advance Medical Staffing hereforth, in this application packet and in any future communication, is true and complete. I understand that any misrepresentation, falsification or willful omission may result in a refusal of employment or dismissal after employment. I understand that a routine inquiry may be made during the processing of this application so as to acquire information concerning my employment record, education, licensure, certification, general reputation, character, background and work performance. I authorize educational institutions, employers, law enforcement authorities, organizations and individuals having relevant information concerning me to release such information. I release all concerned from any liability in connection therewith. Furthermore, I understand that if I am employed, my employment and compensation can be terminated, with or without cause or notice and at any time, at the option of either the company or myself. I understand that any employee manuals, handbooks or policy statements that effect employment are subject to change at any time and shall not be construed as a contract or a guarantee of continued employment. No representative of the company, other than the Chief Executive Officer of Advance Medical Staffing or one designated by the Chief Executive Officer, has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the foregoing. I understand that many of the medical facilities served by Advance Medical Staffing require a physical examination and/or drug testing of personnel and that I may be asked to participate as a condition of placement. By submitting this Application electronically, I agree that the same constitutes my signature to this Application, and Advance Medical Staffing may rely upon the same as an electronic signature. © Advance Medical Staffing, rev 12-99

Step 1 of 4

General Information

Education & Training

Employment History 1

Employment History 2

Employment History 3

Military Experience

[Disclosure of dishonorable or general discharge will not necessarily disqualify application or termination after employment.]

Background

If Yes:

IMPORTANT: PLEASE READ CAREFULLY