Registration: Staff One Plus Inc

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* required field
APPLICANT INFORMATION
 

ADDITIONAL INFORMATION
Date of Birth
Social Security No.
Disipline
Date Available to Work
Desired Wage

Drivers License
State
Expiration Date

Emergency Contact

Emergency Contact Name
Emergency Contact Phone
Emergency Contact Relationship

Employment Profile
Have you ever been convicted of a crime other than a minor traffic violation?
 Yes  No
If you will be employed on a visa, please specify type of work visa

Medical Employment Profile (Only to be filled out by Medical Applicants)
1. License Type
License Number
State
Expiration Date


2. License Type
License Number
State
Expiration Date
Certification

Education
College Name and Location
Graduation Date
Diplomas/Degrees Received

Employment
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

Applicant's Certification and Agreement

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

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Thank you for your interest!
 
 
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