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Online Employment Application


Please enter your personal data below.

Name:
SS#:
Other name(s) under which you have been employed


Email:
Current Address:
City: State: Zip Code:
Home Phone:
Cell Phone:
Permanent Address (if different from current address):
City: State: Zip Code:
Permanent Phone #:
Have you ever been employed by NurseNet, TheraNet or StaffingPlus? Yes No
If yes, Dates:
Facility:
Position:
Do you have any relative(s) employed by NurseNet, TheraNet or StaffingPlus?
Name:
Relationship:
If hired, can you furnish proof that you are either a citizen of the United States or legally permitted to work in the United States? Yes No
Type of Visa:
Have you ever been convicted of a Felony? Yes No
Have you ever been convicted of a
Drug-Related Crime or Misdemeanor?
Yes No
Have you been named in a Medical-Profession Liability Suit with the last five years? Yes No
If yes to any above please explain:

Please list all previous addresses for the past seven years starting with your most recent.

Address:
State:
Zip:
Address:
State:
Zip:
Address:
State:
Zip:
Address:
State:
Zip:
Address:
State:
Zip:
Address:
State:
Zip:
Address:
State:
Zip:

Employment Interests
Position desired or area of interest:
RN PT OT SLP COTA PTA Other
If "Other" please describe:
Specialty:
Geographic Area of interest:
Type of employment you are seeking:
Full Time Per Diem Part Time Temporary Travel
Available Start Date:
Salary Desired:

Education
College:
Location:
Year Graduated:
Type of Degree:
College:
Location:
Year Graduated:
Type of Degree:
Professional or Technical School:
Location:
Year Graduated:
Type of Degree:
High School:
Location:
Year Graduated:
Clinical Internships / Experience:

Licensure
State of
Original Licensure:
Active: Yes No
License #:
Additional Licensures
State: Active: Yes No License #
State: Active: Yes No License #
State: Active: Yes No License #
State: Active: Yes No License #
State: Active: Yes No License #
State: Active: Yes No License #
Have you ever had disciplinary action
taken against any of your licenses? Yes No
If yes, please explain:
Certifications
BCLS Certified: Yes No Expires:
ACLS Certified: Yes No Expires:
Approved Course Certifications
Course Name: Cert. Date:
Course Name: Cert. Date:
Course Name: Cert. Date:
Course Name: Cert. Date:
Course Name: Cert. Date:
Course Name: Cert. Date:
Course Name: Cert. Date:
Course Name: Cert. Date:


Employment History

Please list your previous employers, starting with the current or most recent employer.

Are you currently employed at this time? Yes No

Employer Name: Number of beds:
Address:
City: State: Zip Code:
Type of Facility: Hospital Teaching Trauma SNF
Other:
Charge/Management Experience: Yes No
Supervisor Name:
Supervisor Phone #:
Specialty Experience
1. # of beds:
2. # of beds:
3. # of beds:
Employment Dates: To Yearly Salary:
Full Time Part Time
Reason For Leaving:
May we contact this employer? Yes No
Was this a travel assignment? Yes No
If yes, what agency?


Employer Name: Number of beds:
Address:
City: State: Zip Code:
Type of Facility: Hospital Teaching Trauma SNF
Other:
Charge/Management Experience: Yes No
Supervisor Name:
Supervisor Phone #:
Specialty Experience
1. # of beds:
2. # of beds:
3. # of beds:
Employment Dates: To Yearly Salary:
Full Time Part Time
Reason For Leaving:
May we contact this employer? Yes No
Was this a travel assignment? Yes No
If yes, what agency?


Employer Name: Number of beds:
Address:
City: State: Zip Code:
Type of Facility: Hospital Teaching Trauma SNF
Other:
Charge/Management Experience: Yes No
Supervisor Name:
Supervisor Phone#:
Specialty Experience
1. # of beds:
2. # of beds:
3. # of beds:
Employment Dates: To Yearly Salary:
Full Time Part Time
Reason For Leaving:
May we contact this employer? Yes No
Was this a travel assignment?   Yes No
If yes, what agency?

Referrals - we offer a referral bonus so please enter your friends contact information and ask about our bonus
Name:
Phone #:
Email:
 
References - please fill in contact info for at least two professional references
Reference #1 Name:
Phone #:
email address:
 
Reference #2 Name:
Phone #:
email address:

 

Electronic Signature

The statements made in this application are true and complete to the best of my knowledge.  I understand that falsification will be cause for immediate termination.  StaffMEDICAL is an equal opportunity employer.

By typing in your full name (first and last name) and pressing submit, below, you consent to submitting your Human Resources documentation online. You can request exact copies of this document for your records. If at some point you wish to withdraw your consent to complete your documents online, please call the HR Hotline at (727) 669-7202 and let us know so that we can send you the documents by mail.

Type your full name:
Date:

 

Any Additional Comments Please:


If you are offered employment through StaffMEDICAL those offers are contingent upon your undergoing a medical examination and required laboratory tests and immunization history as defined on the Physical Exam Form to determine that you are protected from communicable diseases and able to perform the duties of the position.  Your signature below indicates your understanding to comply.  By signing below, you are also authorizing StaffMEDICAL to perform a complete background check.

The Fair Credit Reporting Act, as amended by the Consumer Reporting Reform Act of 1996, requires that we advise you that for purposes of employment, promotion, reassignment or continued employment with StaffMEDICAL. [the "Company"], a consumer report and/or investigative consumer report [i.e. background check] may be obtained by the Company, which may include information on your education, former employers, motor vehicle and felony and misdemeanor records. If you are not employed as a result of an investigative consumer report, the Company will notify you in writing and provide you with a copy of the report, the name, address and telephone number of the provider of the report, and a description of your rights as a consumer as required by federal law.

I HAVE READ THIS BACKGROUND CHECK AUTHORIZATION FORM. I UNDERSTAND ITS CONTENTS AND I HEREBY AUTHORIZE StaffMEDICAL, TO OBTAIN BACKGROUND CHECKS AS DISCUSSED. I UNDERSTAND THAT OBTAINING SUCH BACKGROUND CHECKS MAY REQUIRE THE RELEASE OF INFORMATION FROM MY PERSONNEL RECORD/FILE TO THE CONSUMER REPORTING AGENCY. StaffMEDICAL HAS MY PERMISSION TO OBTAIN SUCH REPORTS AT ANY TIME BEFORE OR DURING MY EMPLOYMENT. I AUTHORIZE StaffMEDICAL, TO CONSIDER THE RESULTS OF ANY BACKGROUND CHECK WHEN DECIDING WHETHER TO OFFER ME A JOB, OR WHEN MAKING FUTURE DECISIONS REGARDING MY EMPLOYMENT (INCLUDING RETENTION, PROMOTION OR REASSIGNMENT).