Team Staffing

Team Staffing is an Equal Opportunity Employer and does not discriminate because of race, color, age, sex, religion, national origin, disability, veteran's status, marital status, or other status protected by law. It is the policy of Team Staffing to recruit, hire, promote for all job classifications on the basis or merit, qualifications and competence. This applies to all categories of employment. PLEASE FILL OUT ALL INFORMATION REQUESTED ON THIS APPLICATION. Fields in Red require an answer for the form to successfully submit
Position Applying for: (Check all that apply) RN LPN PCA NA CNA Clerical Maintenance Other

Years of Related Experience	Date Available to begin work:

Personal Information
Last Name
First Name
M.I.
Maiden / Suffix
Street Address
City
State
Zip
Home Telephone
Cell/Alternate Telephone
Emergency Contact Person
Emergency Telephone

By What Source were you referred to Team Staffing for employment?
List name of VEC, Newspaper, Career Day/Job Fair or Employee/Client:
Is there any reason you are unable to perform all of the physical duties of the position for which you have applied? If Yes, please describe:
Can you perform all of the duties, with or without reasonable accommodations, of the position for which you have applied? If No, please describe:
Have you ever been discharged or asked to resign by an employer? If Yes, please explain reason(s)
Are you lawfully authorized to work in the United Stated of America?
Are there foreign languages you can interpret/translate? List of Foreign Languages:
Are you currently with or ever worked with another healthcare agency? Please list all healthcare agencies and salaries:

Conviction(s) of a crime does not automatically bar employment. Factors such as age at time of offense, sentenced time and rehabilitation will be taken into account in determining effect on suitability for employment.
Have you ever committed, been convicted of, plead guilty to, or plead nolo contendre to a felony or a misdemeanor (excluding traffic violations) in Virginia or outside of the jurisdiction of Virginia? If Yes, please explain:
Have you ever committed, been convicted of, plead guilty to, or plead nolo contendre to any offense involving sexual molestation, sexual abuse, or rape, including a deferred sentence in Virginia or outside of the jurisdiction of Virginia? If Yes, please explain:
Are you currently involved in any pending charges, pleadings of guilt or nolo contendre to a felony or a misdemeanor (excluding traffic violations) in Virginia or outside of the jurisdiction of Virginia? If Yes, please explain:
Are you currently involved in or recovering from any form of drug or alcohol abuse? If Yes, please describe:
Have you ever had your nursing license or certification revoked, suspended, or have had any disciplinary actions against you /your license? If Yes, please explain:
Are you involved in any pending or future malpractice claims? If Yes, please explain:
Do you have a current and unrestricted driver's license?
Has your driver's license ever been suspended, revoked or placed on probation? If Yes, please explain:

Education
High School
High School Name
High School City, State
High School Course/Subject
High School Last Level Completed
High School Graduated/Degree
College/Graduate School
College/Graduate School Name
College/Graduate School City, State
College/Graduate School Course/Subject
College/Graduate School Last Level Completed
College/Graduate School Graduated/Degree
Business School / Technical School
Business / Technical School Name
Business / Technical School City, State
Business / Technical Sch Course/Subject
Business / Technical Sch Last Level Completed
Business / Technical School Graduated/Degree

Other Qualifications
Typing (WPM)	Shorthand (WPM)	Word Processing (WPM)	Numeric/10-Key Adding Machine
Other (please specify)
Is there anything else you would like us to know about yourself?

Employment History
Current or Last Employer
Telephone
Address
City
State
Zip Code
Position Held
Starting Salary
Ending Salary
Date Employment Started
Date Separated
Nature of Duties:
Reason for Leaving:
May we contact your current employer for a reference?

Previous Employer
Telephone
Address
City
State
Zip Code
Position Held
Starting Salary
Ending Salary
Date Employment Started
Date Separated
Nature of Duties:
Reason for Leaving:
May we contact your this employer for a reference?

Previous Employer
Telephone
Address
City
State
Zip Code
Position Held
Starting Salary
Ending Salary
Date Employment Started
Date Separated
Nature of Duties:
Reason for Leaving:
May we contact your this employer for a reference?

Personal References (non-family)
Name
Address
Business/Position
Telephone

Name
Address
Business/Position
Telephone

Name
Address
Business/Position
Telephone

FOR LICENSED OR CERTIFIED PROFESSIONAL APPLICANTS
State License or Certification
Expiration Date
Number
Nurse Aide Certificate
State
CPR Date
Expiration Date

Attach Resume
Please note you can only upload Doc, Docx, PDF, TXT or RTF file types
READ CAREFULLY In the event my application is accepted for consideration, I authorize an investigation of all statements contained in this application. I also hereby release any and all persons, companies, or agencies responding to such investigation from any damage due to releasing any information they have regarding me, whether or not it is in their records, pertaining hereto. I understand that all reference information provided will be kept confidential. I understand successful completion of the matters set forth above is a prerequisite to employment or continued employment. I swear and affirm that the information contained in this application is true and accurate. I further understand that misrepresentation of facts asked for on this application will generally result in my application not being further considered by Team Staffing, and/or will generally result in dismissal from employment no matter when discovered. I understand that nothing contained in this employment application is intended to create an employment contract between me and Team Staffing. If at some point an employment relationship is established, I also understand that my employment status will be at will, which means that my employment may be terminated by me or Team Staffing at any time, for any reason. If I am employed, I agree to comply with all of the rules and regulations of Team Staffing. I hereby acknowledge that I have received my Team Staffing Employee Handbook and have been given an opportunity to ask any questions regarding the contents therein. I hereby agree that I will abide by all rules and regulations as outlined in my Employee Handbook and that violation of any rules and regulations may result in my immediate termination. Medical Authorization Release: I hereby give my permission to my doctor and medical facility to release my most recent Tuberculosis test and/or X-Ray, Hepatitis Screening, and/or shot history, and other necessary medical documentation to Team Staffing for the purpose of obtaining employment with Team Staffing.
By Checking this box I agree that all information provided is true and accurate to the best of my knowledge.

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By submitting this form I agree that I have read and agree to the above terms
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Online Application