Shiftboard: Basic Profile Registration

Registration: Staff One Plus Inc

If you have not yet registered for access to our online scheduling system, please complete the following form.

* required field

* First Name

* Last Name

* Home Phone

Mobile Phone

Current Address

City

State

* Zip Code

* Email

Date of Birth

Social Security No.

Disipline

Date Available to Work

Desired Wage

Drivers License

State

Expiration Date

Emergency Contact Name

Emergency Contact Phone

Emergency Contact Relationship

Have you ever been convicted of a crime other than a minor traffic violation?

Yes No

Are you either a U.S. Citizen or can you submit verification of your legal right to work in the U.S.?

Yes No

If you will be employed on a visa, please specify type of work visa

1. License Type

License Number

State

Expiration Date

2. License Type

License Number

State

Expiration Date

Certification

College Name and Location

Graduation Date

Diplomas/Degrees Received

1. Employer

Street

City, State, Zip

Dates employed from

Dates employed to

Position Held

Unit Specialty (for Medical Applicants only)

Hourly Wage

Avg. Patient Ratio (for Medical Applicants only)

Hospital Beds (for Medical Applicants only)

Unit Beds (for Medical Applicants only)

Travel Assignment (for Medical Applicants only)

Yes No

Reason for leaving

Supervisor Name

Supervisor's Phone

3. Employer

Street

City, State, Zip

Dates employed from

Dates employed to

Position Held

Unit Specialty (for Medical Applicants only)

Hourly Wage

Avg. Patient Ratio (for Medical Applicants only)

Hospital Beds (for Medical Applicants only)

Unit Beds (for Medical Applicants only)

Travel Assignment (for Medical Applicants only)

Yes No

Reason for leaving

Supervisor Name

Supervisor's Phone

2. Employer

Street

City, State, Zip

Dates employed from

Dates employed to

Position Held

Unit Specialty (for Medical Applicants only)

Hourly Wage

Avg. Patient Ratio (for Medical Applicants only)

Hospital Beds (for Medical Applicants only)

Unit Beds (for Medical Applicants only)

Travel Assignment (for Medical Applicants only)

Yes No

Reason for leaving

Supervisor Name

Supervisor's Phone

4. Employer

Street

City, State, Zip

Dates employed from

Dates employed to

Position Held

Unit Specialty (for Medical Applicants only)

Hourly Wage

Avg. Patient Ratio (for Medical Applicants only)

Hospital Beds (for Medical Applicants only)

Unit Beds (for Medical Applicants only)

Travel Assignment (for Medical Applicants only)

Yes No

Reason for leaving

Supervisor Name

Supervisor's Phone

I certify all the information submitted by me on this application is true
and complete. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision and hereby release and waive any claim against STAFF-ONE PLUS, INC. and its personnel which may arise from such investigation. I further understand if any false information, omissions, or misrepresentations are either contained in my application or given during any interview and are discovered, my application may be rejected and, if I am employed, my employment may be terminated at any time.

In consideration of my employment, I agree to conform to STAFF-ONE PLUS, INC. rules and regulations as well as those of the client employer. I agree my employment is “at-will” and my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at either my, STAFF ONE PLUS, INC. or the client employer’s option. I also understand and agree the terms and conditions, of my employment may be changed, with or without cause, and with or without notice at any time by STAFF-ONE PLUS, INC. or the client employer.

This application for employment shall be considered active for a period of
90 days. Any applicant wishing to be considered for employment beyond this time period should notify STAFF-ONE PLUS, INC. at that time.

I understand if I am hired, I will be required to provide proof of identity
and information for compliance with the Immigration Reform and Control Act.

I wish to be contacted by a representative of STAFF-ONE PLUS, INC.
regarding insurance and benefits availability, prior to employment.

Signature

Date

We store cookies and other data on your device to help us deliver our services. By using Shiftboard, you agree to our use of cookies and confirm that you have read and accept our privacy policy.

Thank you for your interest!

Error