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)
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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