APPLICATION

**IF YOU ARE USING A PHONE TO ACCESS THIS FORM, TURN IT SIDEWAYS FOR OPTIMAL VIEWING**

Welcome!! As part of the hiring process with Reliant Staffing, you will need to complete an application. Included with the application is a Disclosure and Authorization section for you to sign electronically, consenting to various background checks. By completing the authorization form, you are giving consent to Reliant Staffing, LLC. to verify the information you provided throughout the application.
Did you already speak with someone from our office? If so, who did you speak with?
How did you learn about Reliant? (If you were referred, please tell us who referred you.)

DISCLOSURE 1: Reliant is only interested in hiring staff who have strong clinical skills, who can work independently and those who act like professionals at all times. Agency staff are expected to be flexible, good communicators, responsible, helpful, friendly and provide a high level of care to their patients. Reliant Staffing is not interested in hiring staff who do not follow directions, have a history of excessive call offs, tardiness, lack accountability, poor communicators or other behavioral issues on the job. I've read the above statement and understand.
DISCLOSURE 2: Reliant is not your typical healthcare staffing company. We are not interested in hiring staff who only want to pick up here and there. We want staff who can communicate their availability and schedule a minimum of 24 hours a week on average in advance. We understand there are weeks that our staff will work less than the minimum due to illness, vacations, etc. Again, the expectation is an average of 24 hours a week. I've read the above statement and understand.
DISCLOSURE 3: Reliant uses technology that helps us manage our employee files, schedule our staff, maintain compliance, process payroll and improve communication. We use these technologies in an effort to promote efficiency, reduce errors and provide a high level of service to our staff and facilities. As a result, our staff must be able to use technology by having the ability to send/receive text messages and emails. I've read the above statement and understand.

Personal Information
First Name
Last Name
Phone Number

Area CodePhone Number
Email Address
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
How long have you lived in the above state?
Date of Birth
What is your Specialty?
Has your professional license ever been suspended, revoked or managed by PNAP? If yes, please explain:

Who do we contact in the event of an emergency?
Emergency contact phone number:

Area CodePhone Number
When can you start?

MonthDayYear
Date
How many hours a week do you want to work?
Can you pass a drug screen?
Are you able to send and receive texts?
Do you have reliable transportation?
How frequently do you call off work?

Select all of the shifts you are willing to work:

Rows	Morning (7-3)	Afternoon (3-11)	Night (11-7)
Weekdays
Weekends

Do you have a criminal record? If so, please explain:
Are you pregnant, have disabilities or any other health issues that require us to assist you in the work place? If yes, please explain:
Do you have any issues with getting to work on time? If yes, please explain:

CURRENT or MOST RECENT EMPLOYER
Company
Specialty:
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Start Date
End Date
List all employers in the last five years:

REFERENCE #1 (Please provide professional references; co-workers or supervisors)
FULL NAME
How long have you known this person
How do you know this person?
Can we contact this person?
Phone Number

Area CodePhone Number
REFERENCE #2 (Please provide professional references; co-workers or supervisors)
FULL NAME
How long have you known this person
How do you know this person?
Can we contact this person?
Phone Number

Area CodePhone Number
REFERENCE #3 (Please provide professional references; co-workers or supervisors)
FULL NAME
How long have you known this person
How do you know this person?
Can we contact this person?
Phone Number

Area CodePhone Number

Reliant Staffing is always looking to hire awesome people. If we end up hiring your referral and they work 240 hours you will receive a $250 referral bonus! If you can think of anyone please let us know!!
Name:
Phone Number:
Specialty:

DISCLOSURES
ELECTRONIC SIGNATURE CONSENT

As part of the selection process at Reliant Staffing, the "Company," you will need to consent to a background check electronically. By typing your name, you are consenting to receive any communications (legally required or otherwise) and all changes to such communications electronically. To use the website, you must provide at your own expense an Internet connected device that is compatible with the minimum requirements outlined below. You also confirm that your device will meet these specifications and requirements and will permit you to access and retain the communications electronically each time you access and use the website.

SYSTEM REQUIREMENTS TO ACCESS INFORMATION

To receive and view an electronic copy of the Communications you must have the following equipment and software:

A personal computer or other device which can access the Internet. Your access to this page verifies that your system/device meets these requirements. An Internet web browser which can support 128-bit SSL encrypted communications, JavaScript, and cookies. Your system or device must have 128-bit SSL encryption software. Your access to this page verifies that your browser and encryption software/device meet these requirements.

SYSTEM REQUIREMENTS TO RETAIN INFORMATION

To retain a copy, you must either have a printer connected to your personal computer or other device or, alternatively, the ability to save a copy through use of printing service or software such as Adobe Acrobat®. If you would like to proceed using paper forms, please contact Reliant Staffing.

WITHDRAWAL OF ELECTRONIC ACCEPTANCE OF DISCLOSURES AND NOTICES

You can also contact us to withdraw your consent to receive any future communications electronically, including if the system requirements described above change and you no longer possess the required system. If you withdraw your consent, we will terminate your use of the CSS Inc. website and the services provided through CSS Inc. website.

To ensure that a signature is unique and to safeguard you against unauthorized use of your name, your IP address has been recorded and will be stored along with your electronic signature. Please note that if you wish to submit your Disclosure and Authorization Forms electronically, Reliant Staffing, LLC. requires that you include your social security number or user identification. All your information will be encrypted and transmitted via our secure website.

DISCLOSURE FOR INVESTIGATIVE CONSUMER REPORT

Reliant Staffing (the "Company") may request an investigative consumer report about you from a third-party consumer reporting agency, in connection with your employment or application for employment. An "investigative consumer report" is a background report that includes information from personal interviews (except in California, where that term includes background reports with or without information obtained from personal interviews). The most common form of an investigative consumer report in connection with your employment is a reference check through personal interviews with sources such as your former employers and associates, and other information sources. The investigative consumer report may contain information concerning your character, general reputation, personal characteristics, or mode of living. You may request more information about the nature and scope of an investigative consumer report, if any, by contacting the Company.

If adverse action is taken resulting from information obtained, in whole or in part, from an investigative consumer report from a consumer reporting agency, you will have the option to receive a copy of the report from Reliant Staffing, LLC. Reliant Staffing, LLC can be contacted at 2366 Golden Mile Highway #411, Pittsburgh, PA 15239 or by phone/fax at (412) 215.5959

DISCLOSURE REGARDING BACKGROUND INVESTIGATION

Reliant Staffing (the "Company") may obtain information about you from a third-party consumer reporting agency for employment purposes. Thus, you may be the subject of a "consumer report" which may include information about your character, general reputation, personal characteristics, and/or mode of living. These reports may contain information regarding your credit history, criminal history, social security verification, motor vehicle records ("driving records"), verification of your education or employment history, or other background checks.

You have the right, upon written request made within a reasonable time, to request whether a consumer report has been run about you and to request a copy of your report. These searches will be conducted by Reliant Staffing, LLC,

(412) 215.5959, 2366 Golden Mile Highway #411, Pittsburgh, PA 15239. To the extent permitted by law, the Company may obtain consumer reports from any outside organization throughout the course of your employment.

ACKNOWLEDGMENT AND AUTHORIZATION

[IMPORTANT -- PLEASE READ CAREFULLY BEFORE SIGNING ACKNOWLEDGMENT]

I acknowledge receipt of the DISCLOSURE REGARDING BACKGROUND INVESTIGATION and certify that I have read and understand both of those documents. I hereby authorize the procurement of "consumer reports" and/or "investigative consumer reports" at any time after receipt of this authorization and, if I am hired, throughout my employment. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by Reliant Staffing, LLC can be contacted at 2366 Golden Mile Highway #411, Pittsburgh, PA 15239, http://www.ReliantStaffing.com, another outside organization acting on behalf of Reliant Staffing ("the Company"), and/or the Company itself. I agree that a facsimile ("fax"), electronic or photographic copy of this Authorization shall be as valid as the original.
CONSENT:
Your Signature
Last 4 of SSN:

Should be Empty:

Personal Information