Application Compassion In Care Nurse Staffing, LLC

Application for employment
Name

First NameLast Name
Email
example@example.com
Date Of Birth

MonthDayYear
Date
Social Security Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Date you can start?

MonthDayYear
Date
What type of employment do you desire?

Full TimePart - TimePer - DiemContract
Are you presently employed?
If so, can we contact your present employer?
Job Title
Duties and Responsibilities related to job title:
Compassion In Care Nurse Staffing, LLC is an Equal Opportunity Employer. Please complete your employment history:
Employer 1 start date:

MonthDayYear
Date
Employer 1 End Date:

MonthDayYear
Date
Employer 1 Name and address:
Employer 1 Job title and duties:
Employer 1 Reason for Leaving:
Employer 2 Start Date:

MonthDayYear
Date
Employer 2 end date:

MonthDayYear
Date
Employer 2 Name and address:
Employer 2 Job title and duties:
Employer 2 reason for leaving:
Employer 3 Start Date

MonthDayYear
Date
Employer 3 End Date

MonthDayYear
Date
Employer 3 Title and Duties
Employer 3 reason for leaving
Employer 4 Start Date

MonthDayYear
Date
Employer 4 End Date

MonthDayYear
Date
Employer 4 Title and duties
Employer 4 Reason for leaving?
Three persons, not related to you whom you have know for at least one year.
1st Reference

First NameLast Name
Phone Number
Please enter a valid phone number.
Years Known
2nd Reference

First NameLast Name
Phone Number
Please enter a valid phone number.
Years known
3rd Reference

First NameLast Name
Phone Number
Please enter a valid phone number.
Years known
Elementary School Name
Location
Did you graduate?

YesNo
Middle school name
Location
Did you graduate?

YesNo
High School
Location
Did you graduate?

YesNo
Trade school/College
Location
Did you graduate?

YesNo
Certifications:
Skills related to the job you’re applying for:
The cost of the criminal background check is $28.00 and is due at the time of checkout via the link that will be sent via email.
I, Your Name* understand that by signing this form, I am giving Compassion In Care Nurse Staffing, LLC,
full permission to conduct a criminal history background check for the purposes of employment as an independent contractor.
Today's Date

MonthDayYear
Date
Agree to background check*

Yes, I agree
In the event of a medical emergency, are there any emergency procedures or restrictions on medications of which emergency personnel should be aware?
If yes, please explain.
Emergency contact 1:

First NameLast Name
Phone Number
Please enter a valid phone number.
Emergency Contact 2:

First NameLast Name
Phone Number
Please enter a valid phone number.
I acknowledge that I have received, read and understand the policy and procedures manuel as required by CCNS. I understand that it is my responsibility to comply with all policies and procedures within the manuel. CCNS retains the right to revise its policies and procedures, in whole or in part, at any time.
Agree to terms:*

Yes, I agree
Independent Contractor Acknowledgement and Authorization I certify that the facts contained in this application (and accompanying resume), are true and complete to the best of my knowledge. I understand that any false statement, omission, or misrepresentation on this application is sufficient cause for refusal to hire, or dismissal if I have been employed, no matter when discovered by Compassion In Care Nurse Staffing, LLC. I understand that any employment is conditioned on a background check. I authorize CCNS to thoroughly investigate all statements contained in my application or resume, and I authorize my former employers and references to disclose information regarding my former employment, character, and general reputation to CCNS without giving me prior notice of such disclosure. In addition, I release CCNS, any former employers and all references listed above from any and all claims, demands or liabilities arising out of or related to such investigation or disclosure. I understand and agree that nothing contained in this application, or conveyed during any interview, is intended to create an employment contract. I further understand and agree that if I am hired, my employment will be “at will” and without fixed terms, and may be terminated at any time, with or without cause and without prior notice, at the option of either myself or CCNS. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon CCNS unless made in writing. If I am offered employment, I agree to submit to a medical examination drug test before starting work. If employed, I also agree to submit to a medical examination or drug test at any time deemed appropriate by CCNS and as permitted by law. I consent to such examinations and tests, and I request that the examining doctor disclose confidential and segregated from my personnel file. I understand that my employment or continued employment, to the extent permitted by law, is contingent upon satisfactory medical examination and drug test. I understand that filling out this form does not indicate that there is a position open and does not obligate CCNS to hire.
Agree to terms:*

Yes, I agree
Contractor Signature

Clear
Signature Date

MonthDayYear
Date
Should be Empty:

Application for employment