Personal Information First, Middle, Last Name (exactly as appears on your government identification) Social Security Number Present Street Address City State Zip Code How Long? Previous Address (if different above) City State Zip Code How Long? Telephone Numbers: (Home) ( ) (Work) ( ) (Cell) ( ) Email: In Case of Emergency, Contact: Name: ________________________ Relationship: ___________________ Phone: ________________________ Have you ever worked for @WORK before?
YES NO If YES, Office Location? How were you referred to @WORK? Availability - Job Information Expected Wage?
List your Medical Specialties: Are you legally authorized to work in the United States? Can you perform the essential functions of the job for which you are applying? (see job description) Date Available for Work: Check all for which you are willing to work ?
8 hour shifts 12 hour shifts Overtime Weekends 1st shifts 2nd shifts 3rd shifts How many miles will you drive round trip? What regions or facilities do you prefer? List any facilities for which you will not work: PLEASE CHECK PREFERRED SCHEDULE : Hours Available Monday Tuesday Wednesday Thursday Friday Saturday Sunday TYPE OF ASSIGNMENT DESIRED: Place a CHECK MARK on each day that you have NO WORK RESTRICTIONS, OR: Per Diem ... more. less.
13 Week Temporary to Direct Hire LENGTH OF TIME THIS SCHEDULE IS EFFECTIVE: "I am available to work on this day from/to": (Please list start & end times on each day that you can work) ________ to ________ _______ to ________ _________ to _________ ________ to ________ ________ to ________ ________ to ________ ________ to ________ Comments Regarding Schedule/Availability @ WORK Medical Services Application for Employment 3 Page 1 Education TYPE of Institution Name & Address of Institution Major & Minor Circle Last Year Attended Graduated Degree High School 1 2 3 4 Yes No College 1 2 3 4 Yes No Training or College 1 2 3 4 Yes No Medical Degree 1 2 3 4 Yes No Certificate/License/Specialty Expiration Date Certificate/License/Specialty Expiration Date Certificate/License/Specialty Expiration Date Certificate/License/Specialty Expiration Date Certificate/License/Specialty Expiration Date Have you ever been convicted of a crime, other than a minor traffic violation?<br><br> (conviction may be relevant if job related, but does not automatically bar you from employment) If Yes, explain: Has your professional license or certification ever been investigated or revoked? (if yes, attach a separate sheet with explanation) Have you ever been named as a defendant in a professional liability action? Employment History Dates Worked Describe Your Position/Duties Starting Salary Reason for Leaving Are you presently employed?<br><br> YES NO If YES, may we contact your present employer? YES NO LIST MOST RECENT OR CURRENT EMPLOYER FIRST: FROM Facility/Employer Mo Yr Ending Salary Address TO City, State, Zip Code Mo Yr Departments Worked Supervisor - Title List Facility/Setting Phone # Email Address Explain Any Periods Between Jobs Comments: @WORK Medical Services Application - Page 2 PAST EMPLOYER: Dates Worked Describe Your Position/Duties Starting Salary Reason For Leaving FROM Name of Facility/Employer Mo Yr Ending Salary Address TO City, State, Zip Code Mo Yr Departments Worked Supervisor - Title List Facility/Setting Phone # Email Address Explain Any Periods Between Jobs PAST EMPLOYER: Dates Worked Describe Your Position/Duties Starting Salary Reason For Leaving FROM Name of Facility/Employer Mo Yr Ending Salary Address TO City, State, Zip Code Mo Yr Departments Worked Supervisor - Title Type of Facility/Setting Phone # Email Address Explain Any Periods Between Jobs PAST EMPLOYER: Dates Worked Describe Your Position/Duties Starting Salary Reason For Leaving FROM Name of Facility/Employer Mo Yr Ending Salary Address TO City, State, Zip Code Mo Yr Departments Worked Supervisor - Title List Facility/Setting Phone # Email Address Explain Any Periods Between Jobs PAST EMPLOYER: Dates Worked Describe Your Position/Duties Starting Salary Reason For Leaving FROM Name of Facility/Employer Mo Yr Ending Salary Address TO City, State, Zip Code Mo Yr Depart ments Worked Supervisor - Title Type of Facility/Setting Phone # Email Address Explain Any Periods Between Jobs @WORK Medical Services Application - Page 3 Business or Personal References LIST PERSONS WHO HAVE INFORMATION CONCERNING YOUR WORK HISTORY Name Occupation Business Phone Home Address Phone Title City, State, Zip Code How Long Known? Email address Name Occupation Business Phone Home Address Phone Title City, State, Zip Code How Long Known?<br><br> Email address Applicant Do Not Write In This Box Interviewed by: Date: @WORK Representative Comments: @WORK Medical Services Application - Page 4 Drug Free Workplace Policy Substance abuse has an adverse impact on any employee 9s work, personal and family life, as well as on the ability of @WORK to fulfill its mission to provide the highest quality services to its clients. Substance abuse can cause poor performance, decrease productivity, and create safety hazards. Consequently, @WORK is committed to establishing and maintaining an alcohol and drug-free workplace.<br><br> Illegal Drugs: The use, distribution, sales, offering for sale, possession, purchase, manufacture, or trading of illegal drugs on @WORK 9s premises, or in any other work-related environment is strictly prohibited. The prohibition of illegal drug activity includes occasions when an employee is representing @WORK on one of @WORK 9s client 9s premises or events/meetings beyond normal work hours. Alcohol: Employees are not permitted to consume alcohol while on @WORK 9s premises, client 9s premises, or while conducting @WORK 9s company business.<br><br> This does not include official day or evening functions at which alcohol may be served, as long as use does not prevent employees from performing their jobs satisfactorily or pose any threat to the safety or welfare of the employee or others. Prescription and OTC Drugs: Employees are prohibited from the misuse or abuse of prescription and over-the-counter ( cOTC d) drugs. Employees who are using prescribed or OTC drugs for existing medical conditions must inform their Manager or the Franchise Owner of such health treatment to discuss the necessity of temporary alteration of job duties or assignment if the drugs (1) may have possible side effects which may affect job performance, or (2) alter an employee 9s physical or mental abilities.<br><br> Policy Violations: Employees who violate this policy are subject to disciplinary action, up to and including termination. Applicant Please Initial After Reading: __________ Reporting of Abuse Policy Verbal or physical abuse, neglect, or misappropriation of client facility's or patient/resident's property by our Employees wil l not be tolerated. Any Employee determined to have committed an act of verbal or physical abuse toward a patient or resident of any medical or long-term care facility will be immediately terminated.<br><br> It is every employee's responsibility to immediately report any incidents of actual or suspected abuse to their supervisor, unless the immediate supervisor is the alleged perpetrator. In that case the report is to be made to the @WORK Medical Services Franchise Owner. Any Employee who fails to immediately report any suspected abuse or neglect of a resident will face disciplinary action up to and including termination of employment.<br><br> No reprisal act shall be taken against any employee who reports instances of patient rights violation or patient abuse, neglect or exploitation to the appropriate governmental authority. Applicant Please Initial After Reading: __________ Equal Opportunity Policy It is the policy of @WORK FRANCHISE, INC., and @WORK MEDICAL SERVICES to assure equal employment opportunity practices to all applicants and employees without regard to race, creed, color, religion, national origin, sex, disability, vet eran status, marital status, or any other protected status in accordance with applicable federal, state, and local laws, unless it i s a bona fide occupational requirement necessary to the normal operation of the business. This policy governs all areas of employment with any @WORK Franchise or entity, including, but not limited to, recruiting, hiring, training, assignments, promotions, compensation, benefits, discipline and terminations.<br><br> In addition, @WORK does not discriminate against or provide any preference for any employee or applicant in work assignments, does not invite or honor discriminatory job orders or requests by clients, and does not ccode d applications or documents to record the status of any applicant or employee. We support all employment laws regarding equal opportunity, discrimination, and affirmative action. We also support the code of ethics of the cAmerican Staffing Association d (ASA) in regard to equal opportunity employment and all other policies.<br><br> We require our Franchises and all staff members to adhere to this same code of ethics and that all employees operate within the guidelines of State and Federal laws. Applicant Please Initial After Reading: __________ @WORK Medical Services Application - Page 5 @ WORK Medical Services Application - Page 6 Harassment Policy It is the policy of AtWork Franchise, Inc., and @WORK Medical Services, that all employment relationships shall be conducted in an environment that is not hostile or offensive. Harassment based on an individual 9s age, race, creed, color, religion, national origin, sex, sexual orientation, disability, or marital status, or any other basis prohibited by applicable local, state, or federal law will not be tolerated at any @WORK location.<br><br> Harassment includes, but is not limited to: Verbal harassment , such as making a joke or comment that refers to certain ethnic group, race, sex, nationality, age, disability, sexual preference, religion or belief, epithets, derogatory comments, vulgar or profane words and expressions, or slurs: Physical harassment , such as assault and blocking, impairing or otherwise physically interfering with an individual 9s normal work or movement; Visual forms of harassment , such as derogatory posters, cartoons or drawings; or Sexual harassment , such as unwelcome sexual advances or requests for sexual favors; verbal, visual or physical conduct of a sexual nature, such as name calling, obscene jokes, sexually suggestive comments or insulting sounds; graphic or verbal comments of a sexual nature about a person 9s anatomy; or displaying at work sexually suggestive objects, posters, drawings or pictures. If you believe that you have been subject to harassment by a supervisor, management official, fellow employee, customer, client, vendor or any other person in connection with your employment at @WORK, you should immediately bring the matter to the attention of your supervisor or placement counselor. If the complaint involves your immediate supervisor or placement counselor or if you feel uncomfortable discussing the matter with your supervisor or placement counselor, report the matter to the Franchise Owner.<br><br> All complaints of harassment will be investigated promptly and, where necessary, corrective action will be taken. Any investigations of such complaints will be treated as confidentially as possible. No employee will be punished or suffer any adverse employment action as a result of bringing any good faith harassment complaint to @WORK 9s attention.<br><br> Any supervisor, agent, or employee who is found to have engaged in harassment or retaliation against an employee for exercising rights protected by this policy will be subject to appropriate discipline, up to and including discharge. Applicant Please Initial After Reading: __________ Safety Policy The goal of @WORK MEDICAL SERVICES is to offer our employees and clients the best employment solutions. To do that, we must provide and ensure the highest level of safety, quality, and service.<br><br> Our methods must exemplify the best service to our clients and employees. We believe that all accidents can be prevented. We believe that safety is not separate from the job; it is how we do our job.<br><br> Accidents are a waste of human potential and a source of pain and economic hardship for the injured worker and his/her family. Accidents also lower the quality of the service we provide to our clients. Accidents disru pt business and increase costs.<br><br> In the personnel industry, it is essential that we work together with our clients and employees to build and maintain a safe and healthy work environment. We do not have economic control of our clients 9 facilities, so it i s important that we have a consultative relationship with our clients to assist in maintaining a safe work environment. Furthermore, by having a safety partnership with our clients, we will aid in maintaining an active and effective accident/loss control program together.<br><br> It is @WORK 9s policy to only provide services to clients who express a willingness to provide a safe working environment for our employees. It is also @WORK 9s policy to only employ individuals who are safety conscious, follow all safety policies, and exhibit safe and responsible work habits. @WORK will not provide employees to work for companies who are involved with high-risk industries, have a high accident rate, or who exhibit a disregard for the safety and well-being of all employees.<br><br> Applicant Please Initial After Reading: __________ @ WORK Medical Services Application - Page 7 _______________________________________ _____________________ Signature Date _______________________________________ Print Complete Name Notification & Agreement PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY BEFORE SIGNING THIS APPLICATION. ONLY THOSE APPLICATIONS THAT ARE SIGNED AND DATED ARE CONSIDERED VALID. IF YOU HAVE ANY QUESTIONS REGARDING THIS STATEMENT, PLEASE ASK THEM BEFORE SIGNING.<br><br> YOUR APPLICATION WILL BE GIVEN EVERY CONSIDERATION, BUT ITS RECEIPT DOES NOT IMPLY YOU WILL BE EMPLOYED. PLEASE READ BEFORE SIGNING: I certify that all answers and statements I have made on this application (and any other accompanying or required documents) are true and complete without omissions. I understand that any falsification, misrepresentation or omission of fact on this application (or any other accompanying or required documents) will be cause for denial of employment or immediate termination of employment, regardless of when or how discovered NO q YES q .<br><br> I understand that my employment may be subject to the satisfactory results of any examination required by the company, including a mandatory urine test to detect drug usage and hereby submit to said testing. I agree to conform to all rules and regulations of the company as they presently exist or are later modified. I agree that, if hired, my employment and compensation can be terminated with or without cause, and with or without notice at any time, at either the company or myself.<br><br> I understand that no recruiter or other company representative, other that the President or Vice President of the company, has any authority to enter into any agreement or contract for employment for any specified period of time, or to make any agreement that contradicts the above. NO q YES q I understand that nothing contained in this employment application or in the granting of an interview is intended to create a contract between the franchise office d/b/a AtWork Medical Services or myself for employment for any specified period of time, or to assure me of any future position, benefits, or terms and conditions of employment, except as specifically stated in a current written agreement signed by the President or Vice President NO q YES q I acknowledge that I have read, understand, and agree with the above @WORK policies. In addition, I hereby authorize any of the persons of organizations named in the application (or other accompanying or required documents) to give you complete information and records regarding my employment, education, character and qualifications.<br><br> This application is valid for only ninety (90) days from the date signed. If I want to be considered for job openings more than ninety (90) days from date signed, I will submit a new application. NO q YES q I consent to having the company contact anyone that it deems appropriate to investigate, including a criminal background check, or verify any information I have given, or to discuss my background, past performance, or suitability for employment.<br><br> I further consent to being discussed by any person so contacted and I waive all rights to bring any action for defamation, invasion of privacy, or any similar cause against anyone contacted as a result of what he or she may say about me. NO q YES q