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Application
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Personal Information
Name
*
First
Last
Date
*
Phone
*
Job Applied For (RN, LPN, CNA, Caregiver, etc)
*
Address
*
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Email
*
Do you provide care for someone covered under the Medicaid Waiver program?
*
Yes
No
Recipient's Name:
*
First
Last
Type of Employment You're Seeking
*
Travel
Contract
PRN
On-Call
Caregiver
Are you 18 years or older?
*
Yes
No
(if you are hired you are required to submit proof of age.)
If hired, can you provide proof you are eligible to work in the U.S?
*
Yes
No
Do you have a valid Driver’s License?
*
Yes
No
Have you ever served in the military?
*
Yes
No
Do you have relatives working for Staff Aid?
*
Yes
No
If Yes- Employee’s Name
Can you perform the essential functions and responsibilities of the position for which you are applying?
*
Yes
No
If not, explain:
Do you require any special accomodation to perform required duties?
*
Yes
No
If yes, explain:
Have you ever been employed with Staff Aid?
*
Yes
No
If yes, when?
How did you find out about this position?
*
Current Employee
Career Fair
Newspaper Ad
Indeed
Search Engine
Social Media
Craigslist
Other
If other
When could you start work?
*
How many hours of week are you willing to work?
*
Upload your resume
Click or drag a file to this area to upload.
Additional Information
Next
Do you have allergies that would affect your work at Staff Aid?
*
Yes
No
If yes, what allergies do you have?
Employment
Are you presently employed?
*
Yes
No
If yes, where?
Have you ever been fired or asked to resign from a job?
*
Yes
No
If yes, why?
May we contact your past employer?
Yes
No
1. Name of employer
Job Titles and Duties
Phone
Start Date
End Date
Address
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Rate of Pay
Supervisor
Reason for Leaving
2. Name of employer
Job Titles and Duties
Phone
Start Date
End Date
Address
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Rate of Pay
Supervisor
Reason for Leaving
Do you have transportation?
*
Yes
No
Professional References
Name
First
Last
Give professional references
Job Title
Phone
Name
First
Last
Give professional references
Job Title
Phone
Education
High School Diploma/ GED
Yes
No
Have you ever worked or attended school under any other name?
Yes
No
If yes, please list name
School Name/ College
Dates Attended
Field of Study
Address
Phone
What skills or additional training do you have that are related to the job for which you are applying?
Emergency Contact
First
Last
Phone
I understand that in processing my application with Staff Aid 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 Staff Aid 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 Staff Aid 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 Staff Aid authorization to release confidential medical information upon the request from Staff Aid clients while I am actively working at the client’s facility and /or during the profiling, credentialing, and placement processes.
*
I Agree
Phone
Submit
