Apply Now Form

* Required Information

Application For Employment

Today's Date

Date Available for Work

Name *

Other Name Used

Current Address *

Email

City *

State

Zip Code *

Social Security Number

Can you provide proof of eligibility to work in the United States

Yes

Emergency Contact

Name *

Relationship *

Phone Number *

Have you ever been convicted of a felony?

Yes

Are you currently employed?

Yes

May We Contact Your Present Employer?

Yes

Education

High School

Address

From

Major

Diploma

Yes

College

Address

From

Major

Certificate

Professional Training / Education

Address

From *

Diploma

Certificate

Other Training

Address

From

Diploma

Certificate

Professional

Speciality areas in which you have performed proficiently in the last two years:

Speciality

Years Of Experience

Speciality

Years Of Experience

Speciality

Years Of Experience

License / Certification

State

Number

Expiration Date

License / Certification

State

Number

Expiration Date

License / Certification

State

Number

Expiration Date

Cardiopulmonary Resuscitation / Basic Life Support Certified?

Yes

Expiration Date

Advanced Cardiac Life Support

Yes

Expiration Date

Other Certifications

Pending Certifications

Has your license or certification ever been under investigation?

Yes

Employment Experience

From

Employer

City

Job Title Or Unit

Charge Experience

Yes

Supervisor

Telephone Number

Reason For Leaving

From

Employer

City

Job Title Or Unit

Charge Experience

Yes

Supervisor

Telephone Number

Reason For Leaving

From

Employer

City

Job Title Or Unit

Charge Experience

Yes

Supervisor

Telephone Number

Reason For Leaving

From

Employer

City

Job Title Or Unit

Charge Experience

Yes

Supervisor

Telephone Number

Reason For Leaving

From

Employer

City

Job Title Or Unit

Charge Experience

Yes

Supervisor

Telephone Number

Reason For Leaving

From

Employer

City

Job Title Or Unit

Charge Experience

Yes

Supervisor

Telephone Number

Reason For Leaving

Professional References

Name *

Phone Number *

Name *

Phone Number *

Name

Phone Number

Agreement

If one of our clients offers you a permanent position, your answer should be that AHSS, LLS employs you. You are free to work for the employer of your choice, however, AHSS, LLC is not a permanent placement agency and our client has an obligation to compensate us for the expense, incurred in the recruiting, screening, and placing you. Should you choose to work for our client, notify us and arrangements can be made for you to work for them, through us, as you employee, and our payroll for a 90-day period, at which time we would release from the agreement which you have signed.

I hereby agree in consideration of receiving employment with AHSS, LLC:

To not seek or accept employment from any client of AHSS,LLC to whom I have been assigned, for at least 180 days after the last date of the assignment
That it is my responsibility to provide AHSS, LLC with my available days and hours, on weekly basis, in order to schedule work
That AHSS,LLC is a drug-free workplace and acknowledge that assignments at certain facilities may require submission to drug testing in accordance with federal, state, and local laws
That placement on assignments at certain facilities may require a criminal background investigation.

I certify that the information provided in this application is completed and true to the best of my knowledge. I realize that misrepresentation of facts may be cause for rejection of this application or termination of employment. I authorize AHSS, LLC to contact all of my previous employers and the professional references listed herein and request any, and or all of my former employers to furnish a complete history of my service with them, of the cause of separation.

I hereby release the above parties from any and all liability for damages of whatever nature on account of furnishing, receiving or action upon requested information

I, also grant permission to AHSS,LLC to provide the information contained herein to their clients or potentials clients for the purpose of seeking assignments for me. I understand that, if I have not worked for AHSS,LLC for over a year that I may be asked for additional references and employment information.

I understand that completion of this application and AHSS, LLC entire application process does not guarantee my employment. I also understand that AHSS,LLC Incorporation is a temporary staffing service and does not guarantee the availability of work assignments. AHSS, LLC is an equal opportunity employer that doesn't discriminate in respect to hiring,firing, compensation, and all other terms and conditions of privileges of employment on the basis of race, color, national origin, ancestry, sex, age, pregnancy, or related medical conditions, marital status, religious creed, physical handicap not related to the ability to do the job, or a medical related to cancer or age. I understand that my employment is at will and may be terminated at any time without prior notice.

Printed Name

Date

Signature Name *

Date

AHSS, LLC Representative

Licensed Verified

Yes

Date *