All applicants selected for employment with MedStaffers must satisfactorily pass a pre-employment drug screen and criminal background check to be eligible for employment. MedStaffers is an Equal Opportunity and Affirmative Action Employer. MedStaffers only hires individuals who are authorized to work in the United States. This application is subject to the conditions set forth in the Certification and Agreement section on the last page.

MedStaffers is an Equal Employment Opportunity / Affirmative Action Employer.

Full Name (required)
Current Address (required)
City (required)
State (required)
Zip (required)
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Email Address
Position HHACNALPNRN
Please let us know which position you would like to apply for.
Resume Upload
Source of Referral MedstaffersFacebookJob FairIndeedCraigslistNewspaperother
Please let us know how you heard about the position.
Have you ever been convicted of a felony or misdemeanor, or have you ever plead no contest to any criminal charges? If yes, please provide date, city, state and an explanation for all yes responses. Use additional space if necessary. YESNO
Charges explained:
Can you perform the function of the job for which you are applying, either with or without a reasonable accommodation? YESNO
Do you have any relatives employed by Medstaffers? YESNO
If yes, Who/Relationship?

Work Availability
Current Salary
Minimum Salary
Date of available work
Availability FTPT
Work Weekends YESNO
Hours Available
Rotating Shift YESNO
Hour Preference

In case of an emergency, please contact.
Full Name (required)
Current Address (required)
City (required)
State (required)
Zip (required)
Phone Number (required)

Education
Have you graduated from High School or completed the GED equivalent? YESNO
List all degrees that you have received. List your highest degree first. DO NOT list degrees that you are currently working toward:
Major
Degree
School
Are you currently enrolled? YESNO
Last Year Attended:
Years Completed as Undergraduate
Years Completed Graduate

Licensure/Registration/Certification
List of all professional licenses, registrations and certifications. Additional space is available at the end of the application.
Please indicate which of the following certification you currently hold.
CPR   YESNO EXP. DATE  
BCLS YESNO EXP. DATE  
ACLS YESNO EXP. DATE  
NALS YESNO EXP. DATE  
PALS YESNO EXP. DATE  
Please indicate which of the following certification you currently hold.
CCRN   YESNO EXP. DATE  
CEN YESNO EXP. DATE  
CHEM YESNO EXP. DATE  
CRRN YESNO EXP. DATE  
OCN YESNO EXP. DATE  
CNOR YESNO EXP. DATE  
Critical Care Course YESNO EXP. DATE  
Do you have any pending restrictions and or suspensions on your current professional license/registration that would restrain you from performing this position? YESNO
Have you ever been refused professional licensure, or had a license/registration suspended or revoked? YESNO
If yes, please explain.

Employment History- Please list last 3 employers.
Company Name
Supervisors Name/Title (required)
Current Address (required)
City (required)
State (required)
Zip (required)
Phone Number (required)
Titles/Duties
Date Employed
Date Left
Reason for leaving
Final Salary
Company Name
Supervisors Name/Title (required)
Current Address (required)
City (required)
State (required)
Zip (required)
Phone Number (required)
Titles/Duties
Date Employed
Date Left
Reason for leaving
Final Salary
Company Name
Supervisors Name/Title (required)
Current Address (required)
City (required)
State (required)
Zip (required)
Phone Number (required)
Titles/Duties
Date Employed
Date Left
Reason for leaving
Final Salary

References- Please list 3.
Name
Occupation or Title (required)
Firm Address (required)
City (required)
State (required)
Zip (required)
Phone Number (required)
Years Known
Name
Occupation or Title (required)
Firm Address (required)
City (required)
State (required)
Zip (required)
Phone Number (required)
Years Known
Name
Occupation or Title (required)
Firm Address (required)
City (required)
State (required)
Zip (required)
Phone Number (required)
Years Known


I certify that the information I provided in this application is complete and accurate to the best of my knowledge. I understand that any misrepresentation or omission of facts in this application disqualifies me from further consideration, or, if I am employed, is sufficient cause for dismissal. I understand that any alteration of this application’s content or form my be considered cause for disqualification and or termination. I authorize investigation of all statements contained in this application and understand that I me be required to provide verification (diploma, license, type tests, etc.) of information contained in this application. I authorize any and all persons, companies or agencies to release Medstaffers and all information they may have which is relevant to the application process. I also release all such parties from any liability that may result from furnishing information to Medstaffers.

I understand that to be considered as a formal applicant, the position for which I am applying must be specifically identified as open, and recruitment for the position going on at the time this application is received by Human Resources Department.

I understand that, if I have not worked for Medstaffers for over one year, that I may be asked for additional references and employment information.

I understand that if I am employed with Medstaffers, my employment will be at-will. As such, it can be terminated by me or by Medstaffers with our without advance notice, at any time, and for any reason not prohibited by law. I agree that if I am employed by Medstaffers, I will review the information contained in Medstaffers’s General Information Handbook.

I understand that any unemployment offer is contingent upon the following: 1) Producing documents establishing my eligibility to work in the United States; 2) Satisfactorily passing the pre-employment drug screen, criminal background and reference checks; and 3) complying with Medstaffers pre-employment application procedures.

Yes, I agree. By checking “I agree” and submitting this application to Medstaffers, I acknowledge that I have read the certification and agreement and agree to abide by its terms.

Signature

Full Name (required)

Current Address (required)

City (required)

State (required)

Zip (required)

Phone Number (required)

Email Address

Position HHACNALPNRN
Please let us know which position you would like to apply for.

Source of Referral MedstaffersFacebookJob FairIndeedCraigslistNewspaperother
Please let us know how you heard about the position.

Resume Upload

Have you ever been convicted of a felony or misdemeanor, or have you ever plead no contest to any criminal charges? If yes, please provide date, city, state and an explanation for all yes responses. Use additional space if necessary.
YESNO
Charges explained:

Can you perform the function of the job for which you are applying, either with or without a reasonable accommodation? YESNO

Do you have any relatives employed by Medstaffers? YESNO

If yes, Who/Relationship?


Work Availability

Current Salary

Minimum Salary

Date of available work

Availability FTPT

Work Weekends YESNO

Hours Available

Rotating Shift YESNO

Hour Preference


In case of an emergency, please contact.

Full Name (required)

Current Address (required)

City (required)

State (required)

Zip (required)

Phone Number (required)


Education

Have you graduated from High School or completed the GED equivalent? YESNO

List all degrees that you have received. List your highest degree first. DO NOT list degrees that you are currently working toward:

Major
Degree
School

Are you currently enrolled? YESNO

Last Year Attended:
Years completed as undergraduate
Years completed undergraduate


Licensure/Registration/Certification

List of all professional licenses, registrations and certifications. Additional space is available at the end of the application.

Please indicate which of the following certification you currently hold.

CPR   YESNO
EXP. DATE  

BCLS YESNO
EXP. DATE  

ACLS YESNO
EXP. DATE  

NALS YESNO
EXP. DATE  

PALS YESNO
EXP. DATE  

Please indicate which of the following certification you currently hold.

CCRN   YESNO
EXP. DATE  

CEN YESNO
EXP. DATE  

CHEM YESNO
EXP. DATE  

CRRN YESNO
EXP. DATE  

OCN YESNO
EXP. DATE  

CNOR YESNO
EXP. DATE  

Critical Care Course YESNO
EXP. DATE  

Do you have any pending restrictions and or suspensions on your current professional license/registration that would restrain you from performing this position? YESNO

Have you ever been refused professional licensure, or had a license/registration suspended or revoked? YESNO

If yes, please explain.



I certify that the information I provided in this application is complete and accurate to the best of my knowledge. I understand that any misrepresentation or omission of facts in this application disqualifies me from further consideration, or, if I am employed, is sufficient cause for dismissal. I understand that any alteration of this application’s content or form my be considered cause for disqualification and or termination. I authorize investigation of all statements contained in this application and understand that I me be required to provide verification (diploma, license, type tests, etc.) of information contained in this application. I authorize any and all persons, companies or agencies to release Medstaffers and all information they may have which is relevant to the application process. I also release all such parties from any liability that may result from furnishing information to Medstaffers.

I understand that to be considered as a formal applicant, the position for which I am applying must be specifically identified as open, and recruitment for the position going on at the time this application is received by Human Resources Department.

I understand that, if I have not worked for Medstaffers for over one year, that I may be asked for additional references and employment information.

I understand that if I am employed with Medstaffers, my employment will be at-will. As such, it can be terminated by me or by Medstaffers with our without advance notice, at any time, and for any reason not prohibited by law. I agree that if I am employed by Medstaffers, I will review the information contained in Medstaffers’s General Information Handbook.

I understand that any unemployment offer is contingent upon the following: 1) Producing documents establishing my eligibility to work in the United States; 2) Satisfactorily passing the pre-employment drug screen, criminal background and reference checks; and 3) complying with Medstaffers pre-employment application procedures.

Yes, I agree. By checking “I agree” and submitting this application to Medstaffers, I acknowledge that I have read the certification and agreement and agree to abide by its terms.

Signature