Registration: Quality Care Staffing Solutions, Shiftboard

If you have already registered for access to our online scheduling system and you have already received your welcome email message with your temporary password, please sign in using that password. 

If you have not completed this form, thank you for taking a moment to complete and submit the following details.

Thank you for your patience, it might take a few hours or days until your registration has been processed.

* required field

Emergency Contact Information
Emergency Contact Name
Emergency Phone Number
Emergency Contact Notes

Employment Authorization Statement
* Position applied for:
Is there any information we would need about your name or use of another name for us to be able to check your work record? Please specify:
* Do you have any relatives who are presently (or have formerly been) employed by this company?
 Yes  No
* How did you hear about us?
* Have you ever been convicted of a felony?
 Yes  No
* If yes, please explain:
* Are you able to preform the essential functions of the job with or without reasonable accomodations?
 Yes  No
* What reasonable accomodations, if any, would you require?
* Are you able to lift 50 pounds without any restrictions?
 Yes  No

Education Information
* High School
* Location
* Years completed
* Degree/Diploma
* College
* Location
* Years Completed
* Degree/Diploma
* Technical Training
* Location
* Years completed
* Degree/Diploma
* Other Training
* Location
* Years completed
* Degree/Diploma

Work History
* Company #1
* Postion Held
* Address/City/State
* Dates employed (from/to)
* Wage/Salary
* Manager/Supervisor
* Phone Number
Email address
* Reason for leaving
Company #2
Position Held
Dates employed (from/to)
Phone Number
Email address
Reason for leaving

* Reference #1
* Reference #2
* Reference #3

Work Availability
Can you work overtime if needed?
 Yes  No
* How many hours per week are you available to work?
* If your application received favorable consideration, when will you be able to begin work?
* Salary Requested
* Sunday
* Monday
* Tuesday
* Wednesday
* Thursday
* Friday
* Saturday

Equal Opportunity
The following information is optional.
Employment Status
Protected Veteran
 Yes  No
Veteran Status
Disabled Status

It is our policy to check references as part of our hiring process. This may include contacting your former employers, as well as other business associates. We will ask a series of questions about your work experience, character, education and personality. After reading this policy, please indicate your agreement by signing in the space provided. I have read and fully understand the foregoing and voluntarily consent to allow the organization to check my references. Questions may be asked about my work experience, personality, personal habits and education.
I Agree
* Name
* Date

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