Application

JNK Medical Staffing LLC is in the business of recruiting healthcare employees and referring them to work in facilities throughout the United States. We pride ourselves in providing quality care for our patients with dignity and respect.

All of the below items are required for employment and are required to complete your Personnel Record.

Copies of your:

Driver's License or State Identification Card or Passport or Alien Card
Social Security Card
CPR Card
Professional License
Employee Physical Form
Resume
References (3)
W4 Tax Form
Background Check
Hep B Form or Declination
PPD Form
Flu Shot
Direct Deposit Form

Application of Employment

Full Name(Required)

First Middle Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone #

Cell Phone #

Email Address(Required)

Social Security Number(Required)

Date of Birth

Emergency Contact(Required)

First Last

Emergency Contact Phone #(Required)

Position(s) applied for:(Required)

CNA

LPN

Other:

Please describe the position(s) you are applying for:(Required)

Date available(Required)

Type of employment desired:(Required)

Full-Time

Part-Time

Casual/PRN

Please specify the days and hours you are available:

If currently employed, may we contact your employer?(Required)

Yes

Rate of pay expected per hour(Required)

Is there a specific reason you are applying for employment at this company(Required)

Yes

If Yes, please briefly outline the reason:(Required)

Are you legally eligible for employment in this country?(Required)

Yes

Are you available to work overtime if required?(Required)

Yes

Have you applied with this company before?(Required)

Yes

Have you been employed at this company before?(Required)

Yes

If yes, when and at what location?(Required)

Do you have any friends or family employed at this location?(Required)

Yes

Have you been convicted of a crime in the last seven (7) years?(Required)

Yes

If yes, please explain:(Required)

If considered for hiring, will you agree to provide a criminal background check/drug screening?(Required)

Yes

Educational Background

List previous three (3) educational institutions attended, beginning with the most recent.

School Name (1)

School Name (1) Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Did you graduate?

Yes

School Name (1) Degree or Diplomas Earned

School Name (2)

School Name (2) Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Did you graduate?

Yes

School Name (2) Degree or Diplomas Earned

School Name (3)

School Name (3) Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Did you graduate?

Yes

School Name (3) Degree or Diplomas Earned

Please describe what nursing or relevant designations, licenses, or registrations if any, do you possess:(Required)

Include the type, date of most recent registration and valid in which state / province?

Do you have the following:

CPR

FIRST AID

CPR: Last Certified(Required)

First Aid: Last Certified(Required)

Employment Background

Provide the following information beginning with the most recent employer.

Employer (1) Name

Employer (1) Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer (1) - Your Job Title

Employer (1) - Immediate Supervisor and Title and Phone Number

Employer (1) - Start Date

Employer (1) - End Date

Employer (1) - Hourly Rate - Started

Employer (1) - Hourly Rate - End

Employer (1) - Summarize the type of work performed and job responsibilities.

Employer (1) - Reason for Leaving?

Employer (1) - May we contact your refence?

Yes

Employer (2) Name

Employer (2) Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer (2) - Your Job Title

Employer (2) - Immediate Supervisor and Title and Phone Number

Employer (2) - Start Date

Employer (2) - End Date

Employer (2) - Hourly Rate - Started

Employer (2) - Hourly Rate - End

Employer (2) - Summarize the type of work performed and job responsibilities.

Employer (2) - Reason for Leaving?

Employer (2) - May we contact your refence?

Yes

References

List the name. relationship, number of years acquainted, and phone number of the references. (No relatives please).

Reference (1)

First Last

Reference (1) - Relationship

Reference (1) - Years Acquainted

Reference (1) - Phone #

Reference (2)

First Last

Reference (2) - Relationship

Reference (2) - Years Acquainted

Reference (2) - Phone #

Reference (3)

First Last

Reference (2) - Relationship

Reference (2) - Years Acquainted

Reference (2) - Phone #

I certify that all the information I have provided is true, complete and connect.

The information contained within this application, or any cover letter or resume attached is not shared with any third parties. The information is used by the employer only as an aid in the hiring decision making process.

The applicant, by signing the application gives the employer consent to collect the information contained heroin and use for the purpose specified.

I authorize this company to investigate all statements contained on this application. I understand that any misrepresentation or omission of facts called for is cause for immediate disqualification and/or if employed immediate dismissal.

I understand that if I am hired, I will be required to provide criminal background check at my cost, proof of identity and legal authority to work in the USA. proof of certification or educational qualifications, and a drivers license (if applicable).

Furthermore, I understand and agree that if employed. I am free to resign at any time, with or without cause and without prior notice, except the employer reserves the same rights to terminate my employment at any time, with or without prior notice, except as may be required by law. This application does not in any way constitutes an agreement or contract for employment.

Applicant Signature(Required)

Today's Date

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Max. file size: 225 MB.

Application of Employment

Educational Background

Employment Background

References

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