Job Application

1. Employer Information

Employer: Curis Staffing Job Application

It is the policy of Curis Staffing to provide equal employment opportunities to all applicants and employees without regard to any legally protected status such as race, color, religion, gender, national origin, age, disability or veteran status.

2. Applicant Information

Name

Date of Birth

Social Security Number

Home Address

Address Line 1

City

State

Zip Code

Number of years at this address

Daytime phone

Evening phone

Mobile phone *

Email *

Driver's License (State/Number)

Do you have a Professional License

Type of Professional License

Professional License Expiration

Other License – List All

3. Emergency Contact

Who should be contacted if you are involved in an emergency?

Contact Name

Relationship to you

Address

Address Line 1

City

State

Zip Code

Daytime phone

Evening phone

4. Job Position Applied For

5. Qualification

6. Who referred you to our company?

Do you have any friends or relatives who work here? If yes, please list here

7. Have you applied to our company previously?

If yes, when?

8. Are you at least 18 years old?

9. How will you get to work?

10. Are you willing to work any shift, including nights and weekends?

If no, please state any limitations

11. If applicable, are you available to work overtime?

12. If you are offered employment, when would you be available to begin work?

13. If hired, are you able to submit proof that you are legally eligible for employment in the United States?

14. Are you able to perform the essential functions of the job position you seek with or without reasonable accommodation?

What reasonable accommodation, if any, would you request?

15. Applicant's Skills

Check those skills that you have. List any other skills that may be useful for the job you are seeking. Enter the number of years of experience, and circle the number which corresponds to your ability for each particular skill. (One represents poor ability, while five represents exceptional ability.)

Are you ACLS Certified?

ACLS Expiration

Are you BLS Certified?

BLS Expiration

Specialty Nursing Skills (List All)

Skill Years of Experience Rating Are you in contact with our Recruiter?

16. Applicant Employment History – Last 3 Jobs

List your current or most recent employment first. Please list all jobs (including self-employment and military service) which you have held, beginning with the most recent, and list and explain any gaps in employment. If additional space is needed, continue on the back page of this application.

1. Employer Name

Supervisor Name

Address

Address Line 1

City

State

Zip Code

Job Duties

Reason for Leaving

Dates of Employment (Month/Year)

May we contact your last employer?

2. Employer Name

Supervisor Name

Address

Address Line 1

City

State

Zip Code

Job Duties

Reason for Leaving

Dates of Employment (Month/Year)

May we contact your last employer?

3. Employer Name

Supervisor Name

Address

Address Line 1

City

State

Zip Code

Job Duties

Reason for Leaving

Dates of Employment (Month/Year)

May we contact your last employer?

17. Applicant's Education and Training

College/University Name and Address

Did you receive a degree?

If yes, degree(s) received

College/University Name and Address

Did you receive a degree?

If yes, degree(s) received

Vocational School - Name and Address

Did you receive a degree?

If yes, degree(s) received

High School/GED Name and Address

Did you receive a degree?

Other Training (certification, graduate, technical, vocational)

Please indicate any current professional licenses or certifications that you hold

Awards, Honors, Special Achievements

Military Service:

Branch

Type of Discharge

Date of Discharge

Specialized Training (List ALL)

18. References

List any two non-relatives who would be willing to provide a reference for you.

Name

Address

Address Line 1

City

State

Zip Code

Telephone

Relationship

Name

Address

Address Line 1

City

State

Zip Code

Telephone

Relationship

19. Please provide any other information that you believe should be considered, including whether you are bound by any agreement with any current employer:

CERTIFICATION

I certify that the information provided on this application is truthful and accurate. I understand that providing false or misleading information will be the basis for rejecting my application or, if employment commences immediate termination.
I authorize Curis Staffing to contact former employers and educational organizations regarding my employment and education. I authorize my former employers and educational organizations to fully and freely communicate information regarding my previous employment, attendance, and grades. I authorize those persons designated as references to fully and freely communicate information regarding my previous employment and education.
If an employment relationship is created, I understand that unless I am offered a specific written contract of employment signed on behalf of the organization by its CEO, the employment relationship will be "at-will." In other words, the relationship will be entirely voluntary in nature, and either I or my employer will be able to terminate the employment relationship at any time and without cause. With appropriate notice, I will have the full and complete discretion to end the employment relationship when I choose and for reasons of my choice. Similarly, my employer will have the right. Moreover, no agent, representative, or employee of Curis Staffing, except in a specific written contract of employment signed on behalf of the organization by its CEO, has the power to alter or vary the voluntary nature of the employment relationship.

I HAVE CAREFULLY READ THE ABOVE CERTIFICATION, AND I UNDERSTAND AND AGREE TO ITS TERMS.

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