24 Hour Staffing Solutions
24
Hour Solutions Inc.
Nursing
Agency
415-648-6091
Application
for Employment
Last Name ________________________ First _______________ Middle Initial ______
Other names you have used in the past: ________________________________________
Temporary address
Home Telephone (___)__________________ Cell/Pager (___)_________________
Email Address _________________________ Social Security # __________________
Position Desired _____________________ Hours per week available____________
Date Available __________________ M __ T__ W __ Th __ F __ Sat __ Sun __
Areas of interest? _________________________________________________________
Are you employed now? Y N If yes may we inquire of your present employer? Y N
Are you legally entitled to work in
the
If employed, can you submit proof? Y N
|
School Name/Location College/University |
Course of Study |
Years Completed |
Graduate |
Diploma, Degree or Certificate |
|
|
|
|
Y N |
|
|
|
|
|
Y N |
|
|
|
|
|
Y N |
|
|
|
|
|
Y N |
|
|
|
|
|
Y N |
|
I authorize without reservation, 24 Hours Staffing
Solutions, to verify and to release any information contained in this
application including, but not limited to background verifications, searches,
certificates, certifications, educations, employment validations, immigration,
licensures and medical History. I
authorize all present and previous employers, educational institutions, public
agencies, licensing authorities, client facilities, personal and other
references (as well as all representatives of these persons or entities) to
provide all information they may have regarding me. I voluntarily and knowingly release each of
the above and 24 Hour Staffing Solutions from liability, and waive all claims,
arising from such time as I inform 24 Hour Staffing Solutions in writing that I
wish to revoke this authorization.
I certify that the informations provided in this Application are true, correct and complete. I understand that any misrepresentation, omission or falsification on this application is sufficient cause to prevent hiring, or if hired, termination of employment. My signature below acknowledges that I have read and understood the above disclosures, waivers, and representation.
_______________________________ _________ ________________________
Name (print) Date Signature
24 Hour Staffing Solutions
Nursing Agency
Employment History
|
Employer
Name |
Position/Title Shift |
|
Address,
City, State, Zip |
How
many Hours? |
|
Name
of Immediate Supervisor |
Telephone |
|
Department/Floor/Unit |
Employed
from To |
|
Briefly
list Duties & Reponsibilities |
Hourly
Pay |
|
Reason
for leaving? |
|
|
Employer
Name |
Position/Title Shift |
|
Address,
City, State, Zip |
How
many Hours? |
|
Name
of Immediate Supervisor |
Telephone
|
|
Department/Floor/Unit |
Employed
from To |
|
Briefly
list Duties & Reponsibilities |
Hourly
Pay |
|
Reason
for leaving? |
|
|
Employer
Name |
Position/Title Shift |
|
Address,
City, State, Zip |
How
many Hours? |
|
Name
of Immediate Supervisor |
Telephone |
|
Department/Floor/Unit |
Employed
from To |
|
Briefly
list Duties & Reponsibilities |
Hourly
Pay |
|
|
Reason
for leaving? |
|
Employer
Name |
Position/Title Shift |
|
Address,
City, State, Zip |
How
many Hours? |
|
Name
of Immediate Supervisor |
Telephone |
|
Department/Floor/Unit |
Employed
from To |
|
Briefly
list Duties & Reponsibilities |
Hourly
Pay |
|
Reason
for leaving? |
|
|
Employer
Name |
Position/Title Shift |
|
Address,
City, State, Zip |
How
many Hours? |
|
Name
of Immediate Supervisor |
Telephone |
|
Department/Floor/Unit |
Employed
from To |
|
Briefly
list Duties & Reponsibilities |
Hourly
Pay |
|
Reason
for leaving? |
Licensure (please print clearly)
|
Original State Issued by |
License # |
Expiration |
|
|
|
|
|
|
|
|
|
|
|
|
|
Certification |
Life Support |
|
q Critical Care Cert # |
q BCLS Exp.____ |
|
q Chemotherapy Cert # |
q ACLS Exp.____ |
|
q IV Therapy Cert # |
q NRP Exp.____ |
|
q PICC Cert # |
q PALS Exp.____ |
|
q Other Cert # |
q Other |
Employment References
|
Name |
Where Employed |
Position |
Phone/Address |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Personal References
|
Name |
Relationship |
Yrs. Known |
Home telephone |
|
|
|
|
|
|
|
|
|
|
Have you ever held a nursing license under any other
name? Y N
If yes, list name
_________________________________________________
Have you ever had any professional disciplinary
action taken against you or against any of your licenses? Y
N
Have you ever been names as a defendant in a
malpractice action or an action involving a clain of dishonesty or
violence? Y N
Have you ever been convicted of a felony or a crime
involving dishonesty or violence?
Y N
Are you presently or currently out on bail and/or
awaiting trial? Y N
Is there are reason 24 Hour Stafffing Solution would not be able to assign you to any employer that you listed? Y N
Record Years/Months of Previous Experience
|
q Acute Yrs. Months |
q OR Services Yrs. Month |
|
q Ambulatory Yrs. Months |
q Supervision/Mgnt Yrs. Month |
|
q CHHA Yrs. Months |
q Pharmacy Services Yrs. Month |
|
q Continous 1:1 Yrs. Months |
q Ancillary Services Yrs. Month |
|
q IHHC Yrs. Months |
q Other Yrs. Month |
|
q
Neonates/Newborns (birth – 30 days) |
q
Preschooler (3-5 years) |
q
Yound Adults (18-39 years) |
|
q
Infants (30 days – 1 yr) |
q
Older Children (5-12 years) |
q
Middle Adults (39 – 64) |
|
q
Toddler (1-3 years) |
q
Adolescents (12-18 yrs) |
q
Older Adults/Geriatrics (64 + years) |
24
Hour Staffing Solutions is an equal opportunity employer. Prospective employees will receive
consideration without discrimination in accordance with all applicable state
and federal laws prohibiting discrimination in employment because of race, sex,
religion, age, national origin, marital status, medical condition or
disability. Any dispute arising from
this document, the application process, and employment with 24 Hour Staffing
Solutions (whether potential or actual) shall be exclusively governed by the
laws of the State of California and exclusive jurisdiction and venue for all
such matters shall be in the County of San Francisco.
I authorize without reservation, 24 Hours Staffing
Solutions, to verify and to release any information contained in this
application including, but not limited to background verifications, searches,
certificates, certifications, educations, employment validations, immigration,
licensures and medical History. I
authorize all present and previous employers, educational institutions, public
agencies, licensing authorities, Client facilities, personal and other
references (as well as all representatives of these persons or entities) to
provide all information they may have regarding me. I voluntarily and knowingly release each of
the above and 24 Hour Staffing Solution from liability, and waive all claims,
arising from such time as I inform 24 Hour Staffing Solution in writing that I
wish to revoke this authorization.
I agree to fully comply with the policies,
procedures and standards of 24 Hours Staffing Solutions, and client
facilities. I will fully comply, with
any state, federal, statutory, regulatory or governmental requirements to which
either 24 Hour Staffing Solution or Client Facility is subject. These policies, procedures and standards can
be modified from time to time, including any drug & alcohol free
environment policies.
I understand and agree that acceptance of an offer
of employment does not create a contractual obligation upon 24 Hours Staffing
Solution to continue to employ me in the future; that my employment and
compensation can be terminated at will, with or without cause or notice at my
option or the option of 24 Hour Staffing Solutions.
This document does not constitute an offer for
employment and return of this document does not constitute an acceptance of
employment. An employment relationship,
which shall at all times be at-will, can only be created by subsequent written
statement of 24 Hour Staffing Solutions.
I certify that the informations provided in this Application are true, correct and complete. I understand that any misrepresentation, omission or falsification on this application is sufficient cause to prevent hiring, or if hired, termination of employment. My signature below acknowledges that I have read and understood the above disclosures, waivers, and representation.
_______________________________ _________ ________________________
Name (print) Date Signature