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APPLICATION FOR EMPLOYMENT

GENERAL INFORMATION

Date of Birth
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Are you legally entitled to work in the U.S.?

Have you applied to our company previously?

POSITION

Are you able to perform the essential functions of the job you are applying for, with or without reasonable accommodation?

Will Accept:

Shift:

If applicable, are you available to work overtime?

APPLICANT'S EDUCATION AND TRAINING

Did you receive a degree?

Did you receive a degree?

DRIVER LICENSE

Do you have a valid driver's license?

VETERAN INFORMATION (Most recent)

SPECIAL SKILLS

(List all pertinent skills and equipment that you can operate)

WORK EXPERIENCE (Most Recent First)

(Include voluntary work and military experience)
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May We Contact This Employer?

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REFERENCES

(Please list two references other than relatives or previous employers)
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I certify the information contained in this application is true, correct, and complete. I understand that, if employed, false statements reported on this application may be considered sufficient cause for dismissal.

Applicant Signature

Your Healthcare Staffing does not discriminate in any employment practices on the basis of race, color, religion, gender, national origin, age, disability, or other characteristics protected by law. Decisions at Your Healthcare Staffing are made solely on the basis of merit, ability, qualifications, and character. Reasonable accommodation will be made for qualified individuals with known disabilities so long as it does not impose undue hardship on the company. In the event an employee believes there has been unlawful discrimination or harassment, the employee should contact Aaron Robertson or Zachary Elsts to report the complaint.

SECTION 1: PREVIOUS EMPLOYEE INFORMATION AND RELEASE

I hereby authorize

to release the below information to Your Healthcare Staffing, LLC.

 

Applicant Signature
Requested by prospective employer: Your Healthcare Staffing LLC.

Drug Screen Authorization and Consent

I hereby authorize and give full permission to have Your Healthcare Staffing,LLC.and/or there medical company physician send a specimen of my urine and/or blood to a laboratory for screening test using S.A.M.H.S.A standards for the presence of illegal drugs.

I will hold all parties concerned harmless, meaning it will not sue or hold resposible for any alleged harm to me or interfering with my obtaining a job or continuing my employment due to not submiting to the tests or as a result of the tests.This includes, but is not limited to, possible clerical or laboratory error.

This policy and authorization have been explained to me in a language I understand and I have been told that if I have any question they will be answered about the test.I understand this is legal binding document which is binding because Your Healthcare Staffing,LLC. is sending me for the examination and paying for it

I UNDERSTAND YOUR HEALTHCARE STAFFING,LLC. WILL REQUIRE A DRUG SCREEN TEST WHENEVER AN ON-THE-JOB ACCIDENT AND INJURY IS REPORTEED IN ACCORDANCE WITH YOUR HEALTHCARE STAFFING,LLC. POLICY. MY REFUSAL TO SUBMIT TO DRUG TESTING WILL BE GROUND FOR TERMINATION

 

Applicant Signature

DISCLOSURE & AUTHORIZATION FOR RELEASE OF INFORMATION

As a part of our hiring, a background check and investigation will be conducted. We may ask FleetScreen, a consumer reporting agency, to prepare a consumer report and an investigative consumer report prior to your being qualified in the service of Your Healthcare Staffing LLC. The consumer investigative report may consist of contacting all listed prior employers to verify your employment history, job performance and drug/alcohol testing data. It may also include a consumer report to include a check of applicable criminal police or court records. Under the provisions of the Fair Credit Reporting Act (15 USC at 1681-1681u) as amended, before we can seek such a report from FleetScreen, we must have your written permission for FleetScreen to obtain the information and to provide the information to us as part of our analysis of your application for employment with our company

Below you will find an authorization and release for FleetScreen to prepare a consumer report, and for our company to receive, a copy of that report. If you do not wish to execute this release, please return all of the application materials to the person from whom you obtained them.

AUTHORIZATION & RELEASE TO OBTAIN CONSUMER REPORT

Under the provision of the Fair Credit Reporting Act, 15 USC, Section 1681 et. Seq., the Americans with Disability Act and all applicable federal, state and local laws, I hereby authorize and permit Your Healthcare Staffing LLC. to obtain from FleetScreen, a consumer report and investigative consumer report which may include the following:

  • 1. My employment records.
  • 2. Records concerning any driving, criminal history, credit history, and civil records.
  • 3. For Truck Drivers Only- In accordance with the Department of Transportation Motor Carrier Safety Regulations, Section 382,413, information concerning alcohol and controlled substances use for the past three (3) years.
  • 4. Verification of my academic and/or professional credentials; and information and/or copies of documents from any military service.

I understand that the above items, which may constitute "investigative consumer reports", may include information as to my character, general reputation, personal characteristics, and mode of living which may be obtained by interviews with individuals with whom I am acquainted or who may have knowledge concerning any such items of information.

I agree that a copy of the authorization has the same effect as an original.

I hereby release and hold harmless any person, firm or entity that discloses matters in accordance with this authorization, as well as Your Healthcare Staffing LLC. and FleetScreen from liability that might otherwise result from the request for use of and/or disclosure of any or all of the foregoing information

I understand and acknowledge that under provisions of the Fair Credit Reporting Act, I may request a copy of the consumer report or consumer investigative report from FleetScreen, the consumer reporting agency that compiled the report, after I have provided FleetScreen with proper identification. I also understand that before any adverse action is taken based, in whole or in part, on the information in the consumer report, I will be provided a copy of the report, the name, address and telephone number of Fleetscreen, and a summary of my rights under the Fair Credit Reporting Act.

I hereby authorize FleetScreen to obtain and prepare an investigative consumer report as set forth above and to provide that report to Your Healthcare Staffing LLC. as part of its investigation of my employment application.

 

Applicant Signature
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