Date: 9/03/2010
Application Form
Preferred HealthStaff
We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age sex, religion, disability, medical condition, national origin, or marital status.
Personal Information
First Name
*
Address 1
*
Last Name
*
Address 2
City
*
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington DC
West Virginia
Wisconsin
Wyoming
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Home Phone
*
Zip
*
Work Phone
Driver's License #
Mobile Phone
Email
*
Section 1 -
General Information
Number
Question
Effective Date
Expiration Date
2
What position are you applying for?
Caregiver
Other
1.
Date Available?
(required)
N/A
N/A
3.
Can you provide documentation of a driver's license and auto insurance?
(required)
Yes
No
N/A
N/A
4.
Drivers License Experation Date:
(required)
N/A
N/A
5.
Auto Insurace Experation Date:
(required)
N/A
N/A
6.
Have you ever been convicted of, or plead guilty or no contest to, a misdemeanor or felony in this state or any other?
(required)
Yes
No
N/A
N/A
7.
If yes, please explain.
Show Plain Text
Section 2 -
Employment Verification
Number
Question
Effective Date
Expiration Date
1.
Are you a U.S. citizen?
(required)
Yes
No
N/A
N/A
2.
If you are not a U.S. citizen, please indicate VISA type and number.
N/A
N/A
3.
Are you authorized to work in the U.S.?
(required)
I am authorized to work in the U.S. for any employer.
I am authorized to work in the U.S. only for my current employer.
I require sponsorship to work in the U.S.
I do not know my work status.
Section 3 -
Education
Number
Question
Effective Date
Expiration Date
1.
Name of High School:
(required)
N/A
N/A
2.
Location of High School:
N/A
N/A
3.
Did you graduate?
Yes
No
N/A
N/A
4.
Years Attended (From/To):
N/A
N/A
5.
Additional Education (vocational, undergraduate, etc.)
Yes
No
N/A
N/A
6.
If yes, please list the name of the school and years attended (From/To)
Show Plain Text
Section 4 -
Other Training: Certifications/Licenses
Number
Question
Effective Date
Expiration Date
1.
Certifications/Licenses:
Show Plain Text
Section 5 -
Current Employment
Number
Question
Effective Date
Expiration Date
1.
Current Employer:
N/A
N/A
2.
Address:
N/A
N/A
3.
City:
N/A
N/A
4.
State:
N/A
N/A
5.
Zip Code:
N/A
N/A
6.
Start Date:
N/A
N/A
7.
End Date:
N/A
N/A
8.
Hours Worked:
Full Time
Part Time
Temporary
9.
Position/Title:
N/A
N/A
10.
Describe Your Responsibilities:
Show Plain Text
11.
Supervisor's Name/Title:
N/A
N/A
11.
Supervisor's Phone:
N/A
N/A
13.
Reason for Leaving:
Show Plain Text
14.
May we contact?
Yes
No
N/A
N/A
Section 6 -
Employment History
Number
Question
Effective Date
Expiration Date
1.
Last Employer:
N/A
N/A
2.
Address:
N/A
N/A
3.
City:
N/A
N/A
4.
State:
N/A
N/A
5.
Zip Code:
N/A
N/A
6.
Start Date:
N/A
N/A
7.
End Date:
N/A
N/A
8.
Hours Worked:
Full Time
Part Time
Temporary
9.
Position/Title:
N/A
N/A
10.
Describe Your Responsibilities:
Show Plain Text
11.
Supervisor's Name/Title:
N/A
N/A
12.
Supervisor's Phone:
N/A
N/A
13.
Reason for Leaving:
Show Plain Text
14.
May we contact?
Yes
No
N/A
N/A
Section 7 -
Reference 1
Number
Question
Effective Date
Expiration Date
1.
Name:
(required)
N/A
N/A
2.
Company:
(required)
N/A
N/A
3.
Phone:
N/A
N/A
Section 8 -
Reference 2
Number
Question
Effective Date
Expiration Date
1.
Name:
(required)
N/A
N/A
2.
Company:
(required)
N/A
N/A
3.
Phone:
N/A
N/A
Section 9 -
Emergency Contact Information
Number
Question
Effective Date
Expiration Date
1.
First Name:
(required)
N/A
N/A
2.
Last Name:
(required)
N/A
N/A
3.
Address:
N/A
N/A
4.
City:
N/A
N/A
5.
State:
N/A
N/A
6.
Zip Code:
N/A
N/A
7.
Phone 1:
(required)
N/A
N/A
8.
Phone 2:
N/A
N/A
9.
Relationship:
(required)
N/A
N/A
I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above.
