ENS STAFFING EMPLOYMENT APPLICATION FORM

EXCELLENT NURSING SERVICES, INC. EMPLOYMENT APPLICATION

TODAY’S DATE:*

Date

Name*

First NameMiddle InitialLast Name

Address*

Street Address

PLEASE LEAVE BLANK

CityState / Province

Postal / Zip CodeCountry

Contacts (Please put N/A where not applicable, Don't leave Blank.)*

PhoneAlternative PhoneEmail Address

PLEASE PLACE A CHECK MARK BY YOUR RESPONSE OR PROVIDE THE APPROPRIATE INFORMATION

What Region/City will you be working in?

What schedules would you prefer?

How did you hear about us?

Walk InReferralAdvertsOther

Have you worked for this company before:

NoYes

Dates

Date

Do you know anyone who works here? :

NoYes

Name:

Desired Pay: $

Hourly Pay(Minimum, if applicable) Annual Pay(Minimum)Desired Annual Pay

When are you able to start work?:

Date

In what local area do you prefer to work?

Position desired:

Are you authorized to work in the United States?*

YesNo

Federal law requires that emplyers hire only individuals who are authorized to be lawfully employed in the United States. In compliance with these laws, Excellent Nursing Services will verify the status of every individual offered emplyment with the Company. In this connection, all offers of employment are subject to verification of the applicatn’s identity and emplyment authorization, and it will be necessary for you to submit such documents as required by law to verify your identification and emplyment authorization.

Excellent Nursing Services Inc. is an equal opportunity employer and does not discriminate against any applicant or employee because of race, color, religion, sex, national origin, disability, age, or military or veteran status in accordance with federal law. In addition, Excellent Nursing Services Inc. complies with applicable state and local laws governing non-discrimination in employment in every jurisdiction in which it maintains facilities. Excellent Nursing Services Inc. also provides reasonable accommodation to qualified individuals with disabilities in accordance with applicable laws.

Are you under 18 years of age?*

YesNo

If yes, can you furnish a work permit? :

YesNo

Are you capable of performing the essential functions of the job for which you are applying with or without a reasonable accommodation?

Ye sNo

Massachusetts applicants may include any verified work performed on a volunteer basis

COMPANY NAME # 1

YOUR POSITION AND TITLE

FROM

Month / Year

TO

Month / Year

SUPERVISOR’S NAME, TITLE, POSITION

SUPERVISOR’S TELEPHONE NUMBER

COMPANY ADDRESS

CityStateZip Code

TYPE OF BUSINESS

TELEPHONE NUMBER

HOW DID YOU LEAVE YOUR JOB ?

VoluntaryInvoluntary

REASON(S) IF YOU WERE TERMINATED

BRIEFLY DESCRIBE YOUR MAJOR DUTIES

COMPANY NAME # 2

YOUR POSITION AND TITLE

FROM

Month / Year

TO

Month / Year

SUPERVISOR’S NAME, TITLE, POSITION

SUPERVISOR’S TELEPHONE NUMBER

COMPANY ADDRESS

CityStateZip Code

TYPE OF BUSINESS

TELEPHONE NUMBER

HOW DID YOU LEAVE YOUR JOB?

VoluntaryInvoluntary

REASON(S) IF YOU WERE TERMINATED

BRIEFLY DESCRIBE YOUR MAJOR DUTIES

Massachusetts applicants may include any verified work performed on a volunteer basis

COMPANY NAME # 3

YOUR POSITION AND TITLE

FROM

Month / Year

TO

Month / Year

SUPERVISOR’S NAME, TITLE, POSITION

SUPERVISOR’S TELEPHONE NUMBER

COMPANY ADDRESS

CityStateZip Code

TYPE OF BUSINESS

TELEPHONE NUMBER

HOW DID YOU LEAVE YOUR JOB?

VoluntaryInvoluntary

REASONS(S) IF YOU WERE TERMINATED

BRIEFLY DESCRIBE YOUR MAJOR DUTIES

COMPANY NAME # 4

YOUR POSITION AND TITLE

FROM

Month / Year

TO

Month / Year

SUPERVISOR’S NAME, TITLE, POSITION

SUPERVISOR’S TELEPHONE NUMBER

COMPANY ADDRESS

CityStateZip Code

TYPE OF BUSINESS

TELEPHONE NUMBER

HOW DID YOU LEAVE YOUR JOB

VoluntaryInvoluntary

REASON(S) IF YOU WERE TERNINATED

BRIEFLY DESCRIBE YOUR MAJOR DUTIES

HIGH SCHOOL OR PREP AND ADDRESS

MAJOR SUBJECT

DID YOU GRADUATE? YES OR NO

TYPE OF DEGREE OR DIPLOMA

COLLEGE

MAJOR SUBJECT

DID YOU GRADUATE ?

TYPE OF DEGREE OR DIPLOMA

COLLEGE OR GRADUATE

MAJOR SUBJECT

DID YOU GRADUATE ? YES OR NO

TYPE OF DEGREE OR DIPLOMA

ANY OTHER QUALIFICATIONS

MAJOR SUBJECT

DID YOU GRADUATE ? YES OR NO

TYPE OF DEGREE OR DIPLOMA

DESIGNATIONGRANTED BY: (Organization)DATE COMPLETED ( MM/DD/YYYY)

TYPE OF LICENSESTATE GRANTING LICENSELICENSE NUMBER

REFERENCES: Please list three professional references

NAME

RELATIONSHIP

COMPANY

PHONE / ALTERNATE PHONE

NAME

RELATIONSHIP

COMPANY

PHONE / ALTERNATE PHONE

NAME

RELATIONSHIP

COMPANY

PHONE / ALTERNATE PHONE

I have submitted the attached form to the company for the purpose of obtaining employment. I acknowledge that the use of this form, and my filling it out, does not indicate that any positions are open, nor does it obligate the company to further process my application.

My signature below attests to the fact that the information that I have provided on my application, resume, given verbally, or provided in any other materials, is true and complete to the best of my knowledge and also constitutes authority to verify any and all information submitted on this application. I understand that any misrepresentation or omission of any fact in my application, resume or any other materials, or during any interviews, can be justification for refusal of employment, or, if employed, termination from the Company’s employ.

I also affirm that I have not signed any kind of restrictive document creating any obligation to any former employer that would restrict my acceptance of employment with the Company in the position I am seeking.

I understand that this application is not an employment contract for any specific length of time between the Company and me, and that in the event I am hired, my employment will be “at will” and either the Company or I can terminate my employment with or without cause and with or without notice at any time. Nothing contained in any handbook, manual, policy and the like, distributed by the Company to its employees is intended to or can create an employment contract, an offer of employment or any obligation on the Company’s part. The Company may, at its sole discretion, hold in abeyance or revoke, amend or modify, abridge or change any benefit, policy practice, condition or process affecting its employees.

References: I hereby authorize the company and its agents to make such investigations and inquiries

into my employment and educational history and other related matters as may be necessary in arriving at an employment decision. I hereby release employers, schools, and other persons from all liability in responding to inquires connected with my application and I specifically authorize the release of information by any schools, businesses, individuals, services or other entities listed by me in this form. Furthermore, I authorize the company and its agents to release any reference information to clients who request such information for purposes of evaluating my credentials and qualifications.

Temporary/Contract Employment: If employed as a temporary or contract employee, I understand

that I may be an employee of the company and not of any client. If employed, I further understand that my employment is not guaranteed for any specific time and may be terminated at any time for any reason. I further understand that a contract will exist between the company and each client to whom I may be assigned which will require the client to pay a fee to the company in the event that I accept direct employment with the client, I agree to notify the company immediately should I be offered direct employment by a client (or by referral of the client to any subsidiary or affiliated compa- ny), either for a permanent, temporary (including assignments through another agency), or consulting positions during my assignment or after my assignment has ended.

Signature:

Signature:(First initial and Last name)*

DATE:

Date

I authorize the Company to obtain my background report, including investigative consumer reports. I also agree that a copy of this form is valid like the signed original. I understand that, as allowed by law, the Company may rely on this authorization to order additional background reports, including investigative consumer reports, (1) during my employment and (2) from companies other than ADP Screening and Selection Services without asking me for my authorization again, as allowed by law. I understand the Company may order a background report under my legal name and any other names I may have used.

I also authorize the following agencies and entities to disclose to ADP Screening and Selection Services and its agents all information about or concerning me, as allowed by law, including but not limited to: my past or present employers; learning institutions, including colleges and universities; law enforcement and all other federal, state and local agencies; federal, state and local courts; the military; credit bureaus; testing facilities; motor vehicle records agencies; if applicable, worker’s compensation injuries; all other private and public sector repositories of information; and any other person, organization, or agency with any information about or concerning me. The information that can be disclosed to ADP Screening and Selection Services and its agents includes, but is not limited to, information concerning my employment history, earnings history, education, credit history, motor vehicle history, criminal history, military service, professional credentials and licenses and substance abuse testing.

If you live or work for the Company in California, Minnesota or Oklahoma:

Check this box if you would like free copy of your background check report.

If you live or work for the Company in the States listed below, please note the following:

MASSACHUSETTS: If you submit a request to us in writing, you have the right to know whether the Company ordered an investigative consumer report from ADP Screening and Selection Services, which may include any or all of the following: criminal history review, driving record review, credit report review, and employment/education verifications. You may inspect and order a free copy of the report by contacting ADP Screening and Selection Services.

MINNESOTA: If you submit a request to us in writing, you have the right to get from the Company a complete and accurate disclosure of the nature and scope of the consumer report or investigative consumer report ordered, if any, from ADP Screening and Selection Services, which may include any or all of the following: criminal history review, driving record review, credit report review, and employment/education verifications.

NEW JERSEY: If you submit a request to us in writing, you have the right to know whether the Company ordered an investigative consumer report from ADP Screening and Selection Services which may include any or all of the following: criminal history review, driving record review, credit report review, and employment/education verifications. You may inspect and order a free copy of the report by contacting ADP Screening and Selection Services.

NEW YORK: If you submit a request to us in writing, you have the right to know whether the Company ordered a consumer report or an investigative consumer report from ADP Screening and Selection Services which may include any or all of the following: criminal history review, driving record review, credit report review, and employment/education verifications You may inspect and order a free copy of the reports by contacting ADP Screening and Selection Services. By signing below, you certify you have received a copy of Article 23A of the New York Correction Law is being provided with this form.

WASHINGTON STATE: You also have the right to ask ADP Screening and Selection Services for a written summary of your rights under the Washington Fair Credit Reporting Act.

Name*

First nameMiddle nameLast name

Signature:

Signature:(First initial and Last name)*

Date Month/ Day / Year:*

Date

The information requested below is collected solely for aiding the Company in running back- ground check in connection with your application for employment. The employer is requesting that your provide this information to assist in conducting a thorough background check.

Names*

First NameMiddle NameLast Name

For Identification Purposes Only: Date of Birth*

MonthDayYear

Personal Information *

SOCIAL SECURITY #DRIVER'S LICENCE NUMBERSTATE ISSUING LICENCE

Enter Nickname(s) Used

Race*

Enter any other names used (including maiden names):

First NameMiddle NameLast Name

ADDRESSES WITHIN THE PAST SEVEN YEARS

Present Address*

Street Address

Street Address Line 2

CityState

Zip Code

DATES*

From mm/yyyy to mm/yyyy

Address #2

Street Address

Street Address Line 2

CityState

Zip Code

DATES

From mm/yyyy To mm/yyyy

Address #3

Street Address

Street Address Line 2

CityState

Zip Code

DATES

From mm/yyyy To mm/yyyy

Address #4

Street Address

Street Address Line 2

CityState

Zip Code

DATES

From mm/yyyy To mm/yyyy

Address #5

Street Address

Street Address Line 2

CityState

Zip Code

DATES

From mm/yyyy To mm/yyyy

Address #6

Street Address

Street Address Line 2

CityState

Zip Code

DATES

From mm/yyyy To mm/yyyy

Address #5

Address #3

Address #2

DATES

From mm/yyyy To mm/yyyy

Address #6

Address #7

Address #4

Date:

Date

Preferred Contact Email

example@example.com

Dear Applicant,

Thank you for your interest in ENS staffing services. Attached you will find several pre-employment forms to complete at your earliest convenience. Once complete please fax forms to (574)226-2655 or scan and email to customerservice@ensstaffing.com. You may optionally upload your copies below.

Please include the following with your application: You may upload them below.

1) A copy of your current TB test

2) A recent employment physical

3) A copy of your current CPR card

4) A TB card if you are TB certified

Once these forms are received we will set up a date and time for an interview. We look forward to adding you to our team. Sincerely,

File Upload

Browse Files to upload

Please upload any additional copies here.

HR Director.

Rev 11/19

LIST YOUR EXPERIENCE BELOW (MOST RECENT JOB FIRST)

EDUCATION:

PROFESSIONAL DESIGNATIONS:

PROFESSIONAL LICENSES:

PLEASE READ CAREFULLY BEFORE SIGNING APPLICATION

AUTHORIZATION FOR BACKGROUND CHECKS

STATE LAW NOTICES

Please Print Your Legal Name:

ENS BACKGROUND CHECK INFORMATION

TO ALL NURSING NEW HIRES