Consolidated Medical Staffing Application

Position Desired:

Name:

First Middle Last

Social Security:

Present Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Permanent Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Present Home Phone:

Area Code Phone Number

Work Phone:

Area Code Phone Number

Permanent Phone:

Area Code Phone Number

Cell Phone:

Area Code Phone Number

E-Mail Address:

example@example.com

Emergency Contact:

First Name Middle Name Last Name

Relationship:

Emergency Contact Primary Phone Number:

Area Code Phone Number

How were you referred to Consolidated Medical Staffing?

School Flyer Employee Co-Worker Advertisement Other

If Advertisement or Other please explain:

Name of Co-Worker or Employee Referral Source:

Have you ever been employed by Consolidated Medical Staffing before?

Yes No

If yes, when and where?

Have you ever been convicted of or pled no contest to a crime (either felony or misdemeanor) that has not been sealed, expunged, or statutorily eradicated?

Yes No

If yes please complete the following:

Date of Conviction

Date

Place

Offense

Sentence

A “yes” answer will not automatically disqualify you from being considered as a candidate for employment. Convictions will be considered based on the time and nature of the offense and their relationship to the job applied for.

Are you legally authorized to work in the United States?

Yes No

Name and Address

Major/Degree

Graduated (Yes or No)

High School

College or University

Technical or Nursing

Other Education

Please indicate any other information you think would be helpful to us in considering you for employment, such as additional skills, interests, work experience, and accomplishments. (Please exclude information indicative of age, sex, race,religion, color, national origin, ancestry, or disability).

Please list your job history for the past ten years (or last six employers) starting with your most recent. Please complete this section in addition to forwarding an updated resumé and, noting any periods in which you were not employed, please include Military Service.

Employer-1

Employer

Dates Employed

Facility

Salary $ Beginning - Ending

Address

Phone Number

Name of Supervisor

Job Title/ Position

Number of Beds

Patient Ratio

Reason for Leaving

May we contact? Yes or NO

Employer-2

Employer

Dates Employed

Facility

Salary $ Beginning - Ending

Address

Phone Number

Name of Supervisor

Job Title/ Position

Number of Beds

Patient Ratio

Reason for Leaving

May we contact? Yes or NO

Employer-3

Employer

Dates Employed

Facility

Salary $ Beginning - Ending

Address

Phone Number

Name of Supervisor

Job Title/ Position

Number of Beds

Patient Ratio

Reason for Leaving

May we contact? Yes or NO

Employer-4

Employer

Dates Employed

Facility

Salary $ Beginning - Ending

Address

Phone Number

Name of Supervisor

Job Title/ Position

Number of Beds

Patient Ratio

Reason for Leaving

May we contact? Yes or NO

Employer-5

Employer

Dates Employed

Facility

Salary $ Beginning - Ending

Address

Phone Number

Name of Supervisor

Job Title/ Position

Number of Beds

Patient Ratio

Reason for Leaving

May we contact? Yes or NO

Employer-6

Employer

Dates Employed

Facility

Salary $ Beginning - Ending

Address

Phone Number

Name of Supervisor

Job Title/ Position

Number of Beds

Patient Ratio

Reason for Leaving

May we contact? Yes or NO

Regulations and Mandates require that all registered, licensed and certified employees submit proof of same to his or her employer.

State

License Number

Active or Expired

Date of Issue

Expiration Date

1

2

3

Has your license/certification/registration ever been under investigation?

Yes No

license/certification/registration ever been suspended or revoked?

Yes No

Have you ever been disciplined by a licensing authority or other governing authority?

Yes No

If yes to any of these questions, please attach separate sheet with full explanation.

Please mark the shifts on the days that you would be available for work.

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

What regions or facilities do you prefer?

Augusta, GA Raleigh, NC Columbia, SC Florence, SC Memphis, TN Nashville, TN

List any facilities that you will not work for.

List any facilities you have already completed orientation for.

List any facilities in which you may be a DNR.

Verbal or physical abuse, neglect, or misappropriation of client facility's or patient/resident's property by our Employees will not be tolerated. Any Employee determined to have committed an act of verbal or physical abuse toward a patient or resident of any medical or long-term care facility will be immediately terminated.

It is every employee's responsibility to immediately report any incidents of actual or suspected abuse to their supervisor, unless the immediate supervisor is the alleged perpetrator. In that case the report is to be made to the local Consolidated Medical Staffing office immediately.

Any Employee who fails to immediately report any suspected abuse or neglect of a resident will face disciplinary action up to and including termination of employment.

No reprisal act shall be taken against any employee who reports instances of patient rights violation or patient abuse, neglect or exploitation to the appropriate governmental authority.

Applicant Initial After Reading: *

It is the policy of Consolidated Medical Staffing to assure equal employment opportunity practices to all applicants and employees without regard to race, creed, color, religion, national origin, sex, pregnancy, sexual orientation, disability, veteran status, military status, marital status, or any other protected status in accordance with applicable federal, state, and local laws. This policy governs all areas of employment with Consolidated Medical Staffing, including, but not limited to, recruiting, hiring, training, assignments, promotions, compensation, benefits, discipline and terminations. We support all employment laws regarding equal opportunity, discrimination, and affirmative action.

Applicant Initial After Reading: *

I hereby declare that all statements contained in this application are true and correct and that I understand that false or inaccurate information in this application may be considered grounds for immediate termination. I hereby authorize Consolidated Medical Staffing to investigate my applicable background history inclusive of prior employers, driving records, credentials, Licenses, criminal and professional disciplinary histories, and to verify this information. I understand that if employed , my employment will not be for any fixed period of time and I or Consolidated Medical Staffing may terminate my employment at any time. I also authorize Consolidated Medical Staffing to release information pertaining to my application to, and work history with Consolidated Medical Staffing, subject to applicable privacy and other laws, to entities making valid, legal requests for such information. I understand that I may be expected to work on a variety of job assignments within the scope of my training/credentialing, and within any geographical areas per my agreements with Consolidated Medical Staffing. I understand that Consolidated Medical Staffing will attempt to assist me to expedite and maximize my recovery if I become ill or am injured in their employ, and therefore agree to accept light, or modified duty assignments that may be offered to me. I understand my failure to report to Consolidated Medical staffing for work, including light and/or modified duty assignments, will indicate I have voluntarily quit, thereby relinquishing any claim for unemployment benefits. I also agree to submit to a drug screen upon request or as specified in Consolidated Medical Staffing’s substance abuse policy.

Applicant Initial After Reading: *

Signature

Clear

Print Name

Date

Consolidated Medical Staffing Application

Personal Information

Referral Information

General Information

Education

Other Information

Employment History

Licensure

Availability

Preferences

Reporting of Abuse Policy

EEOC Policy

Notifications and Acknowledgments