Application For Employment

* Denotes a required field

Name:  First * Middle Last *  

Social Security Number: *  Present Address:   *

City:  *State: *    Zip:  *

Home Phone:  *   Cell:      Other: 

Emergency Contact / Relationship:  * Phone:  *

Position Applying For: CNA COTA OT LPN PT PTA SLP RN    Full Time / Part Time (Select One)

Are you available to work:    Weekends?    Yes / No  (Select One)*Graveyards?  Yes / No (Select One)*

How did you hear of this job opening ?:  *

Professional License Number:             State:  option selected="selected" value="AA">AA AE AL AK AP AR AZ CA CO CT DC DE FL GU GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VI VT WA WI WV WY

Type of License:    RN LPN CNA         Expiration Date: 

Basic Life Support Certified?:          Yes / No (mark one)        Expiration Date: 

Advanced Life Support Certified?:   Yes / No (mark one)        Expiration Date: 

Recent Tuberculosis Test?:             Yes / No (mark one)        Expiration Date: 

EDUCATION

Other skills / certifications (IV certified, PALS, NRP, etc.): 

WORK EXPERIENCE

Begin with most recent / current job and date back at least 3 years or until the age of 18, whichever comes first.  Account for all periods of unemployment.  Use additional text area after employment record form portion if necessary.

Name of Employer Job Duties (explain in detail)

Position Start Date End Date

City / State Starting Salary Ending Salary

Reason for Leaving Phone Number

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Name of Employer Job Duties (explain in detail)

Position Start Date End Date

City / State Starting Salary Ending Salary

Reason for Leaving Phone Number

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Name of Employer Job Duties (explain in detail)

Position Start Date End Date

City / State Starting Salary Ending Salary

Reason for Leaving Phone Number

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Please Explain any Gaps in Employment Here:

WORK – RELATED REFERENCES

Name: Title: Phone Number:

Name: Title: Phone Number:

Name: Title: Phone Number:

Terms Of Agreement: I certify that the information contained in this application is true and correct to the best of my knowledge and agree to have any of the statements checked by Quality Staffing Services unless I have indicated to the contrary.  I authorize the references listed above to provide Quality Staffing Services any and all information concerning my previous employment and and pertinent information that they may have.  Further, I release all parties and persons from any and all liability of all damages that may result from furnishing such information to Quality Staffing Services as well as from the use or disclosure of such information by Quality Staffing Services or any of its agents, employees or representatives.  I understand that any misrepresentation, falsification or material omission of information on this application may result in failure to receive an offer, of if I am hired, in my dismissal from employment.  In consideration of my employment, I agree to confirm to the rules and standards of the company and agree that my employment and compensation can be terminated at will, with or without cause, and with or without notice at any time, either at my option or at the option of the company. 

By checking this box I agree to all the terms and conditions in this document and verify the information as honest and forthright.