• Staff Assist Employment Application

    Complete this application and submit your information for consideration—qualified applicants will be contacted by Staff Assist.

  • Position Applying For

  • Position(s) Applying For*
  • Desired Employment Type*

  • Applicant Information

  • Format: (000) 000-0000.
  • Date Available to Start*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Transportation and Availability

  • Will you require transportation assistance for any work assignment you accept?*
  • Do you have reliable transportation?*
  • Do you have a valid driver’s license?*
  • Monday Start Time
  • Monday End Time
  • Tuesday Start Time
  • Tuesday End Time
  • Wednesday Start Time
  • Wednesday End Time
  • Thursday Start Time
  • Thursday End Time
  • Friday Start Time
  • Friday End Time
  • Saturday Start Time
  • Saturday End Time
  • Sunday Start Time
  • Sunday End Time
  • Are you willing to work weekends?*
  • Are you willing to work evenings?*
  • Are you willing to work holidays?*
  • Are you willing to work overnight shifts?*
  • Are you willing to accept short-notice assignments?*

  • Qualifications

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  • Can you perform the essential job duties with or without reasonable accommodation?*

  • Employment History

  • Format: (000) 000-0000.
  • Employer 1 Dates of Employment*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Employer 1 Permission to Contact*
  • Format: (000) 000-0000.
  • Employer 2 Dates of Employment*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Employer 2 Permission to Contact*
  • Format: (000) 000-0000.
  • Employer 3 Dates of Employment*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Employer 3 Permission to Contact*

  • Professional References

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • General Eligibility

  • Are you legally authorized to work in the United States?*
  • Can you provide the required identity and work authorization documents?*
  • Have you previously worked for Staff Assist?
  • Are any of your relatives employed by Staff Assist?
  • Have you ever been convicted of, or pleaded guilty or no contest to, a crime other than minor traffic violations?

  • Drug Testing Consent

  • Date Signed*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Background Check Disclosure and Authorization

  • Date Signed*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Applicant Certification

  • Date Signed*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Acknowledge Certifications*
  • Should be Empty: