Application – Firstat Nursing Services

Start Date

day

month

year

Ending Date

day

month

year

Employer Name

Employer Address

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

Supervisor Name

Supervisor Phone #

Area Code

Phone Number

Starting Salary

Ending Salary

Job Title

Reason for Leaving

Duties & Responsibilities

Education

3/8

Employment History II

Start Date(1)

day

month

year

Ending Date(1)

day

month

year

Employer Name(1)

Employer Address(1)

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

Supervisor Name(1)

Supervisor Phone #(1)

Area Code

Phone Number

Starting Salary(1)

Ending Salary(1)

Job Title(1)

Reason for Leaving(1)

Duties & Responsibilities(1)

Employment History

4/8

Employment History III

Start Date(2)

day

month

year

Ending Date(2)

day

month

year

Employer Name(2)

Employer Address(2)

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

Supervisor Name(2)

Supervisor Phone #(2)

Area Code

Phone Number

Starting Salary(2)

Ending Salary(2)

Job Title(2)

Reason for Leaving(2)

Duties & Responsibilities(2)

Employment History II

5/8

Employment History IV

Start Date(3)

day

month

year

Ending Date(3)

day

month

year

Employer Name(3)

Employer Address(3)

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

Supervisor Name(3)

Supervisor Phone #(3)

Area Code

Phone Number

Starting Salary(3)

Ending Salary(3)

Job Title(3)

Reason for Leaving(3)

Duties & Responsibilities(3)

Employment History III

6/8

General

May we contact your current employer?

Yes

Have you ever applied to us before?

Yes

Will you be able to perform the essential job functions you are applying for with or without reasonable accommodation?

Yes

Have you ever been convicted of a crime, excluding traffic misdemeanors and summary offenses, which has not been annulled, expunged or sealed by court? (A yes response does not automatically disqualify you from employment.)

Yes

Employment History IV

7/8

Certification & Authorization

The above information is true and correct. I understand that, in the event of my employment by the Company, I shall be subject to dismissal if any information that I have given in this application is false or misleading or if I have failed to give any information herein requested, regardless of the time elapsed after discovery. I authorize the Company to inquire into my educational, professional licensure and past employment history references as needed to research my qualifications and background for this position. I hereby give my consent to any former employer to provide information about me to Firstat. I will hold Firstat and my former employer harmless from any decision made on the basis that information. I further authorize Firstat to obtain any professional licensure information from any licensing agency regarding any past or current license, including but not limited to any disciplinary or investigative action from my past or present I understand that nothing in this employment application, the granting of an interview or my subsequent employment with the Company is intended to create an employment contract between myself and the Company under which my employment could be terminated only for cause. On the contrary I understand and agree that, if hired, my employment will be terminable at will and may be terminated by me or the Company at any time and for any reason. I understand that no person has any authority to enter into any agreement contrary to the foregoing. I understand that I am required to contact Firstat Nursing Services after the end of each assignment to request a new assignment, and that unemployment benefits may be denied for failure to do so. I also understand that my continued employment is contingent upon me providing and maintaining a current copy of my license, CPR card and current (within one year of being administered) TB for my personnel file at FIRSTAT NURSING SERVICES. I also understand that failure to keep nursing licensure and credentials current is considered willful neglect on my part. I hereby acknowledge that I have read and agree to the above statements.

Signature

Date:

day

month

year

General

8/8

End