Employment Form

* = Required Information

Position applied for

Date

Full Legal Name *

Social Security Number

Address *

Phone *

City

State

Zip

Email *

Other Names used

Previous Addresses: Please list the City and States in which you have lived, worked, attended school, temporary, etc., in the past seven years.

From

City and States

From

City and States

From

City and States

General Information

Date Available for Work

Full Time

Part Time

Temporary

Shift Available to Work

Day

Evening

Over Night

Have you ever been employed by SSHR before?

Yes

If yes, please provides positions and date below:

Are you legally eligible for employment in the United States?
Proof of citizenship or immigration status will be required upon employment)

Yes

Some jobs require employees to be 18 yrs of age or older. Do you meet this requirement?

Yes

If not, can you provide a work permit?

Yes

Have you ever been convicted of a misdemeanor or felony in any jurisdiction?
Convictions do not necessarily disqualify applicant from employment

Yes

If convicted, please explain:

Have you ever been the subject of as substantiated allegation of abuse?

Yes

Do you have a valid driver's license?

Yes

If yes, please provide information below:

State of Isssue

Licence #

Exp. Date

Have you ever been convicted of any moving violations, including but not limited to, alcohol and drug related offense. You must include any suspension, revocation or any occurence involving harm to persons or property while driving. If so please explain.

Education

If you did not complete high school, do you have a hight school equivalency diploma

Yes

Name and Address of Institution

Degree Received

Major

Dates Attended

If you expect to complete an educational program in the near future, please indicate what type of degree or program and expected completion date:

Please list other applicable certificates, certifications or trainings:

Employment History

Start with the most recent or present job. We will contact your last place of employment. List complete information for all fields.

1. Job Title

Duties

Employer

Address

Phone

Fax

Immediate Supervisor

Title

Start Date

End Date

Reason for leaving:

2. Job Title

Duties

Employer

Address

Phone

Fax

Immediate Supervisor

Title

Start Date

End Date

Reason for leaving:

3. Job Title

Duties

Employer

Address

Phone

Fax

Immediate Supervisor

Title

Start Date

End Date

Reason for leaving:

4. Job Title

Duties

Employer

Address

Phone

Fax

Immediate Supervisor

Title

Start Date

End Date

Reason for leaving:

Summarize any special skills and qualifications gained from employment or other experience.

We may contact the employers listed above unless you indicate those you do not want us to contact. Please list the employer and the reason below.

List any additional information including gaps in employment.

Personal References

Cannot be a relative. Must provide at least two personal references who can attest to your character, reputation and personal qualifications. Please provide all information

1. Name

Phone #

Address

Relationship

# of years known

2. Name

Phone #

Address

Relationship

# of years known

3. Name

Phone #

Address

Relationship

# of years known

Employee Application Work History

Work References

Company Name

From

Position

Any military experiences?

Yes

Schedule

Full Time

Part Time

Voluntary

APPLICANT ACKNOWLEDGMENT
I certify that the information in this application is accurate, current and complete. I understand that misstatements or omissions may result in disqualification from further consideration or termi nation of employment. I authorize Solid Sourc e Healt hcare Re sources to investigate my employment history, credentials and to obtain any relevant information (including a criminal background check) needed to make an emplo yment decision. I authorize SSHCR to disclose th is application along with any information about me obtained through reference checks or during the course of the interview process for state, federal, contractual or accreditation audit purposes. I also authorize SSHCR to disclose any of my performance appr aisals, disciplinary records or skill tests for the same p urposes as above. I release SSHCR and any individual or enti ty providing information to SSHCR from all liability for any damages from the disclosure of this information. I also understand and agree that: Passing a medical examination and/or participating in a post - conditional offer medical screening may be required. If medical restrictions cannot be reasonably accommodated, I may not be hired, or if hired, employment may be terminated. I may be subje ct to pre - employment drug testing, or a drug test where a reasonable suspicion exists, or where warranted by circumstances, workplace conditio ns or contractual requirements. I understand and agree that nothing contained in this employment application or in granting of an interview creates an employment contract between SSHCR and myself for either employment or for the providing of any benefit. No promises regarding employment h ave been made to me. If an employment relationship is established, I understand that my employment will be terminable “at will,” that I will have the right to terminate my employment at any time, and that SSHCR will retain a similar right to terminate my em ployment at any time. I understand that should I become employed by SSHCR , my work assignments, schedules and/or work locations are subject to change according to the needs of the business and the clients of Solid Source Healthcare resources LLC

Date

Applicants Signature

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Upload CPR Card Front and Back

Upload Nursing License

Pursuant to Title VII of the Civil Rights Act of 1964 (42 U.S.C. C2000d et seq.) and 45 C.F.R. part 80, section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. d794) and 45 C.F.R. part 84, and the Age Discrimination Act of 1975 (42U.S.C. d6101 et seq.) and 45C.F.R. part 91, the company adheres to an equal opportunity policy for all persons seeking admission as clients or seeking employment or for all person employed by the company. The company does not discriminate becaus e of age, race, color, religion, military status, marital status, gender preference, sex, national origin or disability.