Kind Staffing Application

Employment Application Form:
Thank you for your interest in Kind Staffing Group!

As an agency our clients come to us to provide qualified, well trained staff that can jump in wherever needed. We require all employees to have a minimum of three months experience in a longterm care setting (outside of clinicals) as a CNA, LPN, or RN (DSP experience does not count as CNA experience). If you just recently passed your state exam we are so happy that you're here, but ask that you come back soon to apply!
Personal Information:
Full Name*

First NameMiddle NameLast Name
Other Names you have gone by:

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Format: (000) 000-0000.
E-mail*
example@example.com
How did you hear about us?*
Do you have at least 3 months experience in a longterm care/skilled nursing setting (outside of clinicals) as CNA, LPN, or RN? If no- your application will be saved but we will not proceed with the hiring process. Please check back after a few months! If you are a DSP please do not apply for a CNA position unless you have at least 3 months experience after certification.

YESNO
Position location*

ILLINOIS- BelvidereILLINOIS- ChicagoILLINOIS- Des PlainesILLINOIS- DekalbILLINOIS- FreeportILLINOIS- GalenaILLINOIS- GeneseoILLINOIS- MorrisonILLINOIS- OttawaILLINOIS- ProphetstownILLINOIS- Rock IslandILLINOIS- RockfordILLINOIS- SavannaILLINOIS- SterlingILLINOIS- StronghurstWISCONSIN- Fon du lac- RN 12 wk contractWISCONSIN- La CrosseWISCONSIN- RacineWISCONSIN- West SalemWISCONSIN- WaupacaWISCONSIN- DarlingtonIOWA- BooneIOWA- DavenportIOWA- Des MoinesIOWA- DubuqueIOWA- KalonaIOWA- LansingIOWA- KeokukIOWA- ManchesterIOWA- Fort MadisonIOWA- Cedar RapidsIOWA- Mason CityIOWA- Mount PleasantIOWA- FayetteIOWA- MadridWASHINGTON D.C.
Referred By:
Are You a U.S. Citizen?*

YesNo
Employment Desired:

Select all locations that you're interested in
Position Applying For (Note: At this time DSP and Dietary positions are only available in a few locations- check with your recruiter)*
Date You Can Start*

MonthDayYear
Date
Do you have a current license/certification in the state of the position that you are applying for? We will need to verify this with the state before proceeding with employment.
What states do you carry an active certification/License in?
What is your availablity? Please list days and times that you are available for work.
Are you looking for Full-time/Part-time/PRN? Please list all that apply.*
Do you have a current CPR Certification? (You must have a current certification before we can proceed with your employment unless you are applying for a Dietary Aide or Cook position)*

YESNO
CPR Card Expiration Date: (Upon hire we will need a picture of your card) - Not applicable for Dietary Aide or Cook positions
Date of last Mantoux (TB) Test*
Social Security Number (used to verify your certification/ license)*
Date of Birth*
Education:
High School*
Name of High School Attended
Number of Years Attended*
Graduated?*

YesNo
College
Name of College/University Attended
Number of Years Attended
Graduated?

YesNo
Area of Study/Degree
Current Employment:
Current Employer*
Name of Current Employer or NONE if not Employed
Position*
Salary
Reason for Leaving?
Start Date*

MonthDayYear
Date
May We Contact?

YesNo
Previous Employment:
Previous Employer*
Name of Previous Employer
Position*
Salary*
Reason for Leaving?*
Start Date*

MonthDayYear
Date
End Date*

MonthDayYear
Date
Previous Employer*
Name of Previous Employer
Position*
Salary*
Reason for Leaving?*
Start Date*

MonthDayYear
Date
End Date*

MonthDayYear
Date
REFERENCES- Two professional references are required. Are you able to provide at least two professional, non-family references upon hire?*

YESNO
Send Application:
By clicking the submit button below, I cerity that all of the information provided by me on this application is true and complete, and I understand that if any false information, ommissions, or misrepresentations are discovered, my application may be rejected and, if I am employed, my employement may be terminated at any time.

In consideration of my employment, I agree to conform to the company's rules and regulations, and I agree that my employment and compenstation can be terminated, with or without cause, and with or without notice, at any time, at either my or the company's option.

I also understand and agree that the terms and conditions of my employment may be changed, with or without cause, and with or without notice, at any time by the company.
Should be Empty:

Employment Application Form:

Personal Information:

Employment Desired:

Education:

Current Employment:

Previous Employment:

Send Application: