Position Desired
Date Available:
Type of Employment Desired
Part TimeFull Time
Last Name
First Name
Middle Name
Street Address
City
State/Zip
Home Phone
Alternate Phone
E-mail Address
Do you have a valid Driver’s License?
YesNo
CDL?
Do you have relatives working for Alpha Medical Staffing?
If Yes- Employee’s Name
Have you ever served in the military?
Do you have the legal right to obtain employment in the United States?
Can you perform the essential functions and responsibilities of the position for which you are applying?
Do you speak any other language(s)? Specify
If not, explain
Do you require any special accomodation to perform required duties?
Have you ever worked for Alpha Medical Staffing ? If so, give date(s) of employment and position(s) held:
Do any of your relatives work for for Alpha Medical Staffing ?
If yes, explain:
for? If Yes, State their name
Have you ever been convicted of any criminal or driving offense(s) other than a minor traffic violation?
If yes, written documentation must be provided about criminal offenses from the clerk of court in 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.
Level of education completed:
High SchoolGEDCollege 0-3 yrs
Degree:
AssocBachelorMasters
If degree, specify major:
From
To
Beginning Salary $
Ending Salary $
Name of Employer
May we contact?
Address
Supervisor’s Name:
Phone Number
Title and Duties Performed:
Reason for Leaving
I understand that in processing my application with Alpha Medical 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 Alpha Medical 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 Alpha Medical 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 Alpha Medical Staffing authorization to release confidential medical information upon the request from Alpha Medical Staffing clients while I am actively working at the client’s facility and /or during the profiling, credentialing, and placement processes.
SIGNATURE OF APPLICANT
DATE
