Career Opportunities

Application

Position Applied for
 Certified Nursing Aid Licensed Practical Nurse Registered Nurse

How did you hear about Med Pool Professionals?

Name

Last

First

Middle

Number

Home Number

Mobile Number

Work Number

Address

Current Address

Bldg. / Apt. #

City

State

Zip Code

Current Mailing (if different from street address)

Prior Address

Email Address

Note

This application form is intended for use in evaluating your qualifications for employment. This is not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment, terminating employment. All qualified applicants will receive consideration without discrimination based on sex, martial arts, race, color, age, creed, national origin, sexual orientation, military reserve membership, ancestry, religion, height, weight, use of a guide or support animal because of blindness, deafness or physical handicap, or the presence of disabilities. A conviction will not necessarily bar an applicant from employment. Additional testing of job-related skills may be required prior to employment. After an offer of employment, and prior to reporting to work, you may be required to submit to a medical review and evaluated for the presence of drugs and alcohol. Depending on company policy and the needs of the job, you will be required to complete a medical history form and may be required to be examined by a medical professional designated by the company.

Scheduling

What date can you start? (MM/DD/YYYY)

Which Category do you prefer?

For Which Schedules Are You Available?
 Weekdays Weekends Evenings Nights Overtime Holidays

*Reasonable efforts will be made to accommodate sincerely held moral and ethical beliefs, religious beliefs and practices

Job Related Skills

Note: Do not fill out any part of this section you believe to be non-job related.

If the job requires, do you have the appropriate valid driver’s license?
 yes no

Name on License

DL#

Type

State of Issue

Have you been given a job description or had the essential functions explained to you? yes no

Do you understand these essential functions? yes no

Can you perform the essential functions of his job with or without reasonable accommodations? yes no

Security

List states and counties of residence for the past SEVEN (7) years:

Have you used any other Names or Social Security Numbers other than given above?

 yes no

Please explain why

Have you been convicted of a crime in the past seven years? (Conviction will not necessarily be a bar to employment. In accordance with company policy and applicable state and federal laws, factors such as age at time of the offense, remoteness of the offense, time since last conviction, and nature of the job sought and rehabilitation effort will be reviewed.)

 yes no

Please explain your conviction

PLEASE NOTE: Every question in this next section is mandatory. Since we make every effort to contact previous employers, the correct telephone numbers of past employers is critical. Ask for a phonebook or call information if necessary. FOR EMPLOYERS OUTSIDE THE U.S.A. CURRENT FAX NUMBER IS MANDATORY.

Most Recent Employer

Are you currently working for this employer? yes no

May We Contact? yes no

Company

City

State

Dates Employed

From

To

Job Title

Supervisor Name

Duties

Salary

PER Hour Week Month

Reason for Leaving

2nd Most Recent Employer

Are you currently working for this employer? yes no

May We Contact? yes no

Company

City

State

Dates Employed

From

To

Job Title

Supervisor Name

Duties

Salary

PER Hour Week Month

Reason for Leaving

3rd Most Recent Employer

Are you currently working for this employer? yes no

May We Contact? yes no

Company

City

State

Dates Employed

From

To

Job Title

Supervisor Name

Duties

Salary

PER Hour Week Month

Reason for Leaving

Reference

Name (First and Last) City and State Phone/Cell Number
Relationship Years Known

2nd Reference

Name (First and Last) City and State Phone/Cell Number
Relationship Years Known

3rd Reference

Name (First and Last) City and State Phone/Cell Number
Relationship Years Known

4th Reference

Name (First and Last) City and State Phone/Cell Number
Relationship Years Known

5th Reference

Name (First and Last) City and State Phone/Cell Number
Relationship Years Known

Education

Please choose the highest grade completed  7 8 9 10 11 12 13 14 15 16 16+

If your school records are listed differently than the name previously given please write it here

List Schools

Name City and State Graduated Degree

CERTIFICATION AND RELEASE

I certify that I have read and understand the summary of information on this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts called for in this application, whether on this document or not, may result in rejection of my application or discharge at any time during my employment. I authorize the company and or its agents, including consumer reporting bureaus, to verify any of this information. I release all former employers, persons, schools, companies, and law enforcement authorities from any liability for any damage whatsoever for releasing this information. I also understand that the use of any illegal drugs is prohibited. If company policy requires, I am willing to submit to drug testing to detect the use of illegal substances prior to and during employment.

I agree I disagree

If answers on application do not disappear after clicking "SEND" please check for errors and areas missed.




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