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Arise Health Staffing Agency – Application for Employment

Arise Health Staffing Agency
Application for Employment

Step 1 of 10

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Personal Data
Name*
First Middle Last
Date*
Date Format: MM slash DD slash YYYY
Home Phone
Cell Phone
Email*
Current Address*
Street Address Address Line 2 City State ZIP Code
Previous Address
Street Address Address Line 2 City State ZIP Code
Emergency Contact*
Name Phone Relationship
Gender*
- Male
- Female
Social Security Number*
Date of Birth*
Date Format: MM slash DD slash YYYY
Vehicle (Year, Make)
Driver’s License
- Yes
- No
Driver’s License*
Number State Issued Exp. Date
Position Applying For
- PCA
- CNA
- LPN
- RN
- MDS
- HOUSEKEEPING

Placement Information
Due to the nature of the business, no guarantee can be made as to the schedule or the number of hours worked.
Date Available*
Date Format: MM slash DD slash YYYY
Ideal Number of Hours Per Week
Requested Salary
Hours Available To Work
Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Education
List Business Schools, Colleges Attended And Any Related Classes
High School
- High School
High School*
Name Location Subject Degree Years/Graduation
Vocational/Technical School
- Vocational/Technical School
Vocational/Technical School*
Name Location Subject Degree Years/Graduation
College/Univesity
- College/Univesity
College/Univesity*
Name Location Subject Degree Years/Graduation
N/A
- N/A

Licensure Information
License Type License/Certification Number State Expiration Date

Certifications
ACLS
- ACLS
Expiration Date*
Date Format: MM slash DD slash YYYY
BCLS
- BCLS
Expiration Date*
Date Format: MM slash DD slash YYYY
CPR
- CPR
Expiration Date*
Date Format: MM slash DD slash YYYY
PALS
- PALS
Expiration Date*
Date Format: MM slash DD slash YYYY
IV
- IV
Expiration Date*
Date Format: MM slash DD slash YYYY
NALS
- NALS
Expiration Date*
Date Format: MM slash DD slash YYYY

References
[Please Include at least 3 and Do not Include Relatives]
Name Relationship Phone Number Years

WORK HISTORY
Most Recent Employer
Are You Currently Working for this Employer?
- Yes
- No
If Yes, May We Contact?*
- Yes
- No
Company Name
Phone Number
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Dates Employed
From Month/Year to Month/Year
From To
Position Title
Supervisor’s Name
Summary of Duties

WORK HISTORY
Second Most Recent Employer
Company Name
Phone Number
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Dates Employed
From Month/Year to Month/Year
From To
Position Title
Supervisor’s Name
Summary of Duties

Additional Information
Have you been charged/convicted of a felony and /or misdemeanor/or served time?*
- Yes
- No
If Yes, Please describe incident, city/state and charge?*
Have you ever been a charged perpetrator or appeared on any child abuse registry in the last 10 years?*
- Yes
- No
Are you legally authorized to work in the USA?*
- Yes
- No
Do You Have a Clean Driving Record?*
- Yes
- No
If No, Please Explain?*
Arise Health Staffing Agency is a DRUG FREE WORK PLACE
Can you pass a pre-employment drug test?*
- Yes
- No
I understand that I must report all accidents to my immediate supervisor and to Arise Health Staffing Agency, Inc .*
- Yes
- No
I understand that I must appropriate personal protective equipment (PPE) must be used per health care facility requirements. Failure to not adhering to this, will result in disciplinary action, up to and including termination.*
- Yes
- No

Certification and Release
Please Read The Following Statements Carefully:
In submitting this application, I understand that:
Arise Health Staffing is a DRUG FREE WORKPLACE
1. This application remains active for ninety (90) days and that submission of the application and subsequent pre-employment interviews are not promises (implied or otherwise) of employment. Successful job applicants will be officially notified by Human Resources.
2. I understand that any offer of employment that I may receive will be a conditional offer of employment contingent upon an acceptable pre-employment drug screen and background check.
3. I understand that, if hired, my employment will be at will. That means that my employment is for an indefinite period and that AHSA or I may terminate my employment at any time, for any or no reason, with or without notice or prior disciplinary steps. I further understand that no verbal statements or statements in any AHSA policy, hand book, or other document shall be construed to have altered this at-will nature of my employment.
  No company manager is authorized to make any representations to the contrary.
4. I also understand that all AHSA employees are required to complete a three-month introductory period during which time they are not eligible to use any AHSA employee benefits.
5. I certify that the information provided on this application, along with all other information that I have provided Arise Health Staffing Agency Inc ( AHSA), is accurate and complete. I understand that any misrepresentation or omissions will be cause for not hiring me or terminating my employment if I am hired before such is discovered.
6. If hired, I understand and agree that I will be required to follow AHSA rules, policies, and procedures, as they may be in effect from time to time.
7. I understand that AHSA will undertake, and I so authorize them to do so, any investigation it deems necessary in considering me for employment or, if hired, for my continued employment. I expressly authorize any present or former employer; school, college, or university; credit or finance bureau; law enforcement agency; or any other person to give AHSA any information (written or oral) or records concerning me or my qualifications, employment, credit, reputation, mode of living, education, or criminal record. I unconditionally release AHSA and its representatives and agents as well as all persons from whom they request information from any and all liability relating to such request for information or any information provided.
8. I am responsible for necessary transportation to and from work.
9. I understand Arise Health Staffing Agency, Incorporated does not guarantee a specific work schedule or job assignment.
10. North Carolina General Statutes state that "any applicant for employment who willfully furnishes supplies, or otherwise gives false information on an employment application that is the basis for a criminal history record check under this section shall be guilty of a Class A 1 misdemeanor."
Consent*
I hereby acknowledge that I have read and understand the above statements (1-10) and have not misrepresented the facts on this job application.
Signature/Name*
Date*
Date Format: MM slash DD slash YYYY

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