Employment Application

Join our Team!

Personal Data

Name
Address
Date of Birth
Hours Desired
Shifts Available
Days Available
Preferred Locations/Sites Of Interest To Work
Location/Site
City, State
 
Hospitals, nursing homes, clinics, etc. Make a list including City/State (Max of 5)

Professional Licensure

Include All Applicable Professional Licensure
Type
Number
Expiration
Current States
 
Add as many as necessary.

Applicant Declarations

Are you 18 or older?
Are you eligible to work in the United States legally?
Have you ever been convicted, pled guilty or no contest to a crime?
This includes misdemeanors (except parking violations), gross misdemeanors and felonies. A conviction, guilty plea or no contest will not necessarily disqualify you for employment consideration.
(what, where, when, etc.)
Have you ever been excluded from the Medicare or Medicaid program for conduct that would constitute a misdemeanor, gross misdemeanor or a felony under the law?
Have you ever been disciplined by professional or state ethics or licensing board?
How did you hear about us?

Did anybody refer you to our company?

Education Information

High School
Did you Graduate?
GED?
Diploma Program, Commercial or Technical
Did you Graduate?
College or University
Did you Graduate?
Graduate School
Did you Graduate?

Employment Information

1. Employer (Most Recent)

Employer Info
Supervisor Name
Start Date
End Date

2. Employer

Employer Info
Supervisor Name
Start Date
End Date

3. Employer

Employer Info
Supervisor Name
Start Date
End Date

4. Employer

Employer Info
Supervisor Name
Start Date
End Date

Voluntary Identification

Our company is committed to respectful and equal treatment for all employees. This commitment includes non-discrimination towards applicants and employees on the grounds of race, color, creed, religion, age, sex, disability, national origin, ancestry, sexual orientation, marital status, or with regard to public assistance, or union or non-union status. This prevails throughout the employment relationship, including, but not limited to recruitment, selection, training, transfer, compensation, promotion, demotion, layoff and termination.
Ethnicity
Race

If two or more races, please select “Other” and specify.
Sex/Gender
Disable Veteran
Are you entitled to disability compensation under laws administered by the Veterans Administration for disability rates at 30% or more, or are you a person whose discharge or release from active duty was for a disability incurred or aggravated in the line of duty?
Self-Identification of Disability
You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.

Professional References

No family members/relatives.

Reference One

Reference Info
May we contact this person for a reference?

Reference Two

Reference Info
May we contact this person for a reference?

Reference Three

Reference Info
May we contact this person for a reference?

Reference Four

Reference Info
May we contact this person for a reference?

We Are An Equal Opportunity Employer

Applicant Release, Please read and sign below

I authorize the investigation of my background, including all information contained in this application and information provided in the interview. I understand that misrepresentation or omission of information in connection with my application and interview will be sufficient cause, in and of itself, for rejection or dismissal whenever discovered. I understand and agree that any offer of employment is contingent upon satisfactory completion of Nurse Link Staffing Inc.’s pre-employment investigation, which includes but is not limited to health assessment, criminal history check, educational and work verification, reference checks, a consumer report and any investigation required by local, state, or federal laws. I understand that if I am hired by Nurse Link Staffing Inc., my employment will be for an indefinite period of time and will be “at will,” which means that either Nurse Link Staffing Inc. or I may terminate the employment relationship at any time and for any reason or no reason according to Kansas Labor Laws.

I further understand that, if hired, my at-will employment status may only be changed by the management of Nurse Link Staffing Inc., or myself and that no representative of Nurse Link Staffing Inc. has the authority to make promises, either written/oral or implied, to me concerning my employment. Finally, I also understand that Nurse Link Staffing Inc. may adopt, from time to time, policies or handbooks dealing with benefits and other terms or conditions of employment.

Nurse Link Staffing Inc. reserves the right to change or discontinue these policies and/or handbooks at any time, with or without notice to me. Nurse Link Staffing Inc. strives to provide a safe, healthy and productive work environment and supports a smoke, drug and alcohol-free work environment.
Submission Consent
Date