Position applying for with Action Health Staffing
CNAII
CNA
PCA
RN
LPN
Med Tech
Other
Have you been convicted of a felony in the past 7 years?
Yes
No
A conviction record will not necessarily be a bar to employment. Factors such as age, time of the offense, seriousness, nature of violation and rehab will be taken into account.
Have you ever registered with Action Health Staffing?
Yes
No
Do you have (2) forms of ID, one being a State issued Photo ID & a recent TB Skin Test?
Yes
No
Are you willing to sign a drug screen consent form?
Yes
No
Are you willing to sign a release for criminal records background check?
Yes
No
Do you have the information needed to complete a reference check form?
Yes
No
(Including complete dates, addresses, and phone numbers of your most recent employers)
Are you available for full time employment?
Yes
No
Part-time employment?
Yes
No
Are you available for
Long Term
Short Term
Both
Is this amount
Per hour
Per week
Per month
I hereby declare that all statements contained in this applilcation are true and correct and understand that false or inaccurate information in the application will be the basis for termination. I hereby authorize this company to investigate my background and verify this information. I understand that if employed, my employment will not be for any fixed period of time and may be terminated by the company at any time. I also authorize this company to release the information contained herein and its findings and work history of my employment to other firms or person on request. I also understand and agree that I may be expected to work a wide variety of job assignments and agree to accept assignments for which I am qualified as they become available. I also understand my failure to report to Action Health Staffing for work will indicate I have quit. I also agree to submit to drug and/or contagious disease screen upon request.
