MNIPRE

Health Care Staffing LLC 300 Main Street North Easton MA, 02356 Tel: 508-2724390

Email: :Info@omniprehealthcarestaffing.com Web: https://omniprehealthcarestaffing.com

Omnipre Health Care Staffing is a drug free workplace.

Position Desired Applicant Must Complete

Please note: Print in ink or type. Complete all sections.

Do you have a valid Driver's License?YesNo

Do you have relatives working for Omnipre Health Care Staffing ? Yes No If Yes- Employee's Name Have you ever served in the military? Yes No Do you speak any other language(s)? Specify

Do you have the legal right to obtain employment in the United States?Yes

Can you perform the essential functions and responsibilities of the position for which you are applying? If not, explain:

Do you require any special accomodation to perform required duties? If yes, explain:

Have you ever worked for Omnipre Health Care Staffing ? If so, give date(s) of employment and position(s) held:

Do any of your relatives work for for Omnipre Health Care Staffing ? for? If Yes, State their name

Omnipre Health Care Staffing is an equal opportunity employer.

List any current licenses, certifications, or registrations required for the position for which you are applying. Include date received. Have you ever been convicted of any criminal or driving offense(s) other than a minor traffic violation? YesNo If yes, written documentation must be providedaboutcriminal offensesfromtheclerk ofcourtin the county in which the conviction was made, and about any driving offenses other than minor traffic violations from the motor vehicles office.

You must provide at least three current reference letters and/or the name of individuals with whom a reference interview can be conducted. Please give the full name, mailing address, and phone number of three references who have knowledge of your background and qualifications the field. 1. 2.

Level of education completed: BachelorMasters

Experience List last 5 years of work experience

Omnipre Health Care Staffing is an equal opportunity employer.

Iunderstand that in processing my application with Omnipre Health Care Staffing an investigation may be made in which information is obtained through personal interviews, and a review of information held by law enforcement or other government agencies. I authorize you to verify my past employment and education, criminal records, motor vehicle records, personal references, and other job-related data provided on this application, or via the interview process. I authorize appropriate individuals, companies, institutions, or agencies to release information, and I release them from any liability as a result of such inquires or disclosures. A consumer report may be generated summarizing this information. I further understand and waive my right of privacy in this investigation and release and hold harmless Omnipre Health Care Staffing from any liability. I agree that any decision to hire me is contingent upon the results of my report and certify that all statements and answers on my application, resume, or interview are true and complete to the best of my knowledge. I understand that if any statements are false or that if information has been omitted, this will be cause for disqualification and immediate termination of my employment. If employed, I further authorize Omnipre Health Care Staffing to check my credit, conviction records, and other items listed above as needed, on a continuous basis as it relates to my employment. I am granting Omnipre Health Care Staffing authorization to release confidential medical information upon the request from Omnipre Health Care Staffing clients while I am actively working at the client's facility and or during the profiling, credentialing, and placement processes.

Omnipre Health Care Staffing is an equal opportunity employer.