Preferred Medical Staffing LLC

Reaching out to touch those who needs us

Preferred Medical Staffing, LLC

Employment Application

First Name:
Last Name::
Address: Street City State Zip:
Previous Address: Street City State Zip:
Social Security Number:
Emergency Phone::
Email Address::
Position Applying for::
Date available to work:
Please check the shift(s) days and	Part-time Full-time
times of the week your are	7 am - 3 pm 3 pm - 11 pm 11 pm - 7 am
available to work:	7 am - 7 pm 7 pm - 7 am
	Monday Tuesday Wednesday
	Thursday Friday Weekends
Education and Training:
High School Name:
Street Address City State/Zip:
College/Vocational:
Street Address City State/Zip:
Degree Completed::	yes no
Are you legally authorized to work in the USA?	yes no
Have you ever been convicted of a felony or misdemeanor crime?:	yes no
Have you ever been employed by Preferred Medical Staffing, LLC?:	yes no
If yes, give location(s) and dates(s):
How were you referred to Preferred Medical Staffing, LLC?:
References:
	(Please list 3 individuals with whom you have worked with who were in a position to evaluate your performance.)
1. Name Company Phone:
2. Name Company Phone:
3. Name Company Phone:
Work History:
	List all of your work experience beginning with your most recent job. You will be asked to explan all gaps in employment and what you were doing during that time. Include military experience, summer, part-time jobs and any verifiable work performed on a voluntary basis (Attach additional sheets if necessary.)
Company Name::
Title:
Employment Date::
Company Address:
Salary:
Name of Supervisor:
Phone:
May We Contact?:
Reason for Leaving:
Company Name:
Title:
Employment Date:
Company Address:
Salary:
Name of Supervisor:
Telephone:
May We Contact?:
Reason for Leaving?:
Company Name:
Title:
Employment Date::
Company Address:
Salary:
Name of Supervisor:
Phone:
May We Contact?:
Reason for Leaving:
Other work experience:	Please list any other work related information you think would be helpful to us in consideration you for employment, such as specialized training, certifications, additional work experience, etc.
Experience:
	I certify that the information on this application is current, and accurate. I understand that mistatement may result in termination of employment. I authorize Preferred Medical Staffing, LLC to investigate my employment history and to perform a criminal background check. I authorize Preferred Medical Staffing, LLC to disclose this 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 release Preferred Medical Staffing, LLC and any individual or entity providing information to Preferred Medical Staffing, LLC from all libility for any damages from the disclosure of this information. I may be subject to pre-employment drug testing, or a drug test where a reasonable suspicion exists, or where warranted by circumstances, workplace conditions or contractual requirements. I understand and agree that nothing in this application guarantees employment with Preferred Medical Staffing, LLC. I understand that my employment with Preferred Medical Staffing, LLC is "atwill". I have the right to terminate my empoyment at any time, and Preferred Medical Staffing, LLC retains the same right to terminate my employment at any time.
Applicant's Signature:	Please type name.
Date:
	Agree Disagree

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