Medical Staffing Application

							                                                   Medical Staffing Application for Employment – Equal Opportunity Employer

Personal Information
Name (Last Name First)                           First                                     M. I.                                      Today’s Date:




Present Address:                                 City                                      State                                      Zip Code


Permanent Address                                City                                      State                                      Zip Code


Phone Number                                     Cell Phone                                Referred by:

(           )
Employment Desired                                         Date you can start:                                     Social Security Number
Position:

Are you employed now?                                      If so, may we inquire of your present employer?         Salary/Hourly Rate Desired:

[ ] yes [ ] no                                             [ ] yes [ ] no
Are you legally authorized to work in the United           Ever been employed by Choice Staffing?                  When:
States?
           [ ] yes [ ] no                                  [ ] yes   [ ] no                                        Where:
Employment Information
RN________        LPN_________ Tech Speciality______________________________ ___ CNA ________ GNA_________ Care Giver_________

Clinical Experience             Area of Clinical Experience:                                                                          Length of Experience




Education History                                       Name & Location                        Years Attended        Did you graduate        Subjects Studied
High School                                                                                                          [ ] yes [ ] no


College and/or Education Program                                                                                     [ ] yes [ ] no




    General Information
    Subjects of special study/research work:


    Special Training/Skills:


                                                                                 Branch:                   Rank at discharge

                                                                                 From ______________ to__________________
                                                                                 Type of Discharge:            Explain if less than Honorable:

                      Military Service

    Have you ever been convicted of a felony? [ ] yes [ ] no If yes explain:


    Drivers License                                         Do you have a valid license [ ] yes [ ]       State    Expiration Date     License #      CDL [ ]A [ ]B
                                                            no
Licensure:                                              License No.                                             Expiration Date
State of Original License:

State of Present License:                               License No.                                             Expiration Date


                                                        License No.                                             Expiration Date



Former Employers (List below last three employers, starting with last employer first

Date – Month – Year          Name & Address of Employer                       Salary                 Position                         Reason For Leaving

From:

To:

From:

To:

From:

To:


References: Give below the names of three persons not related to you, whom you have known at least one year:

Name                                         Address                                          Business                                              Years Known




Authorization: I hereby certify that the information provided on this application is true and complete. I hereby authorize Choice Staffing, Inc. to investigate fully
all information contained in this application.


Date_____________________                              Signature ___________________________________            Do Not Write Below

Interviewed by:_____________________________________________Date_____________

Remarks_________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

Neatness                                                                            Character




Personality                                                                         Ability




Facility Hired for ________________________ Position________________________________ Hire Date_____________ Salary/hr. Rate_________