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Please Fill Out this Job Application Form:
* indicates a required field

Application Date* Last Name*
First Name* Middle
Social Security* Number
   
Street Address* City*
County* State* Zip*
Phone* Message Number
   
Previous Street Address City
County State Zip
   
    JOB INTERESTS
Position Applying for*:
 
RN PT Pharmacist
LPN OT Pharmacy Tech
CNA ST Surgical Tech
Respiratory Therapist X-Ray Supplemental Staffing
Hospital Clinic Nursing Home
Gastric Psychiatric Med/Surg
Pediatric/Maternal Child ICU/CCU Labor/Delivery
Oncology OR Private Care
Intermittent Care Extended Care Hospice
Rehabilitation Security-Private Residential Care
IV Therapy    

 
Date Available to Work*
Shift Available*
Full-Time Part-Time On-Call
7am-3pm 3pm-11pm 11pm-7am
Other    
Days Available*
Monday Tuesday Wednesday Thursday
Friday Saturday Sunday  
   
  EDUCATION AND TRAINING
High School Name*
Address* City* State/Zip*
Highest Grade Completed*
   
Other School*
Address* City* State/Zip*
Major Emphasis* Degree Completed*
   
Level and Type* GPA*
   
    LICENSE/CERTIFICATION
License Type License/Certification Number
State Expiration Date
   
License Type License/Certification Number
State Expiration Date
   
License Type License/Certification Number
State Expiration Date
   
CPR Expiration Date* Date of your last Physical* Last TB/CXR Date*
   
    GENERAL INFORMATION

Are you authorized to work in the United States*
 
Yes  
No
  Should you be employed by AllStaff Medical Resources, you will be required to provide the documentation proving your eligibility to work in the USA

Have you ever been convicted of a felony*
 
Yes
No
  This does not apply if the conviction has been expunged, is contained in a sealed record, or was a juvenile conviction. A criminal conviction will not necessarily bar you from employment. We will consider the nature of the crime, the time which has expired since its occurrence and any rehabilitation you have undergone.

Any and all employment information regarding rate of pay and PT information is confidential
 
  How were you referred?
 
Newspaper Job Fair/Open House AMR Employee
Trade Publication Employment Agency Other
  AMR Employee Name and Location
  Other Referral Source
   
    WORK EXPERIENCE
  List all of your work experience beginning with your most recent job. You will be asked to explain all gaps in employment and what you were doing during that time. Include military experience, summer jobs, part-time jobs and any verifiable work preformed on a voluntary basis.
Company Name* Address*
Title* From* To*
Salary*
   
Describe your most recent job duties and accomplishments*
Name of Supervisor* Phone* May We Contact?*
  Are your employment records listed under another name?*
  Explain your reason for leaving*
 
   
Company Name Address
Title From   To
Salary
  Describe your job duties and accomplishments:
 
Name of Supervisor Phone May we Contact?
  Are your employment records under another name
  Explain your reason for leaving
 
   
Company Name Address
Title From To
Salary
   
Describe your job duties and accomplishments
Name of Supervisor Phone May we contact?
  Are your employment records listed under another name?
  Explain your reason for leaving
 
  Please list any other work related information you think would be helpful to us in considering you fro employment, such as specialized training, certifications, additional work experience, etc.
 
 
    PERSONALITY PROFILE
  What kind of job are you seeking, what areas or specialties?
 
  Will you travel or take an assignment, what areas of the country?
 
  Why do you want to work per diem?
 
  Do you have a current TB or x-ray date and expiration? ACLS date and expiration BCLS date and expiration License date state(s) and expiration CCRN date and expiration any other certificates, skills or designations?
 
  What is your level of commitment to working with us?
  PRN  Part time  Full time  Short term assignment  Long term
  How would you describe your work ethic?
 
  How many times have you called in sick over the past year? 
  When you leave a position how much notice do you give? 
  How would you describe your communication skills?
 
  What’s more important, your job performance or your pay? Why?
 
  If you make a mistake what would you do?
 
  When you have a question about a procedure or policy what do you do?
 
  How do you feel about rotating your workdays or working weekends?
 
  How many hours do you want to work per week?
 
  What is your preference days, evenings or nights?
 
  Do you want PRN full time or part time?
  Have you worked for an agency before? Yes  No
  If so which one and at what facilities?
 
  What did you like or dislike about working for them?
 
  Do you have preferences to what facility or unit you would like to return to or not go to again?
 
  How do you handle a bad experience at a worksite? How do you communicate this to your supervisors?
 
  If you could choose a perfect work environment what would it be?
 
  If you could choose a perfect working relationship with peers and others what would it be?
 
  How would you try to contribute to making any of the 2 questions above happen?
 
  What is your schedule and your availability from month to month?
 
 

We ask that you work a minimum of 3 shifts and a weekend day for a total of 4 shifts per month to be eligible for bonuses.

You are responsible for all your own credentials and licensing and annual renewals. If you work fulltime for at least one quarter we will reimburse for basic credentials CPR,TB,drug etc.  If you work six months or more on assignment fulltime we will reimburse for ACLS as well as basics.  If you have no write-ups or disciplinary actions during the year you will be eligible for a bonus at the end of the year. 
 
    REFERENCES
Name* Company*
Title* Phone*
   
Name Company
Title Phone
   
Name Company
Title Phone
   
    APPLICANT ACKNOWLEDGMENT:
  I certify that the information in this application is accurate, current and complete. I understand that misstatements or omissions may result in disqualification from further consideration or termination of employment.

I authorize AllStaff Medical Resources to disclose this application in addition to any information about me obtained through reference checks or during the course of the interview process for state, federal, contractual or accreditation audit information. I authorize AllStaff Medical Resources to investigate my employment history, credentials and to obtain any relevant information including a criminal-background-check, needed to formulate an employment decision. I authorize AllStaff Medical Resources to disclose any of my performance appraisal, skills tests or disciplinary records for the purposes stated above. I release AllStaff Medical Resources and any individual or entity providing information to AllStaff Medical Resources from all liability for any damages from the disclosure of this information.

I understand that in the event I become employed by AllStaff Medical Resources, my work assignments, schedules and/or work locations are subject to change according to market demands and the need of the clients of AllStaff Medical Resources. 
 
  I also understand and agree:*

Passing a medical examination and/or participating in a post-conditional offer medical screening may be required. If medical restrictions cannot be reasonably accommodated, I may not be hired, or if hired, employment may be terminated.

 I may be subject to pre-employment drug testing, or a drug test where are reasonable suspicion exists, or where warranted by circumstance, workplace conditions or contractual requirements.


  HIPPA and Confidentiality Agreement: All Patient information in any format is completely confidential. Violation of confidentiality is punishable by this facility and the law. By signing this job application you agree to hold AllStaff Medical Resources harmless for any and all liability.
By typing my name in this box I certify the information contained herein is accurate and complete*             
  Date*
 

Pursuant to Title VII of the Civil Rights Act of 1964 and 45 C.F.R Part 80, Section 504 of the Rehabilitation Act of 1973, as amended and 45 C.F.R. Section 84 and the age discrimination act of 1975 and C.F.R Part 91the agency adheres to an equal opportunity policy for all persons seeking admissions as a client, or seeking employment, and for all persons employed by the agency. The agency does not discriminate because of age, race, color, religion, military status, marital status, gender preference, sex, national origin or disability.
 
 

 
 
      AllStaff Medical Resources, 1777 South Bellaire, Suite 165, Denver, CO 80235 - (303)504-9061