Education and Training (Please list all schools attended)
Certifications: Check All Applicable Certifications
Please list the number of years you have experience in each area (minimum 1 yr EXP.) and are clinically competent to work:
References (Please list three people whom you have worked with in a position to evaluate your performance)
Applicant Acknowledgment of Truth
that the information contained with this application is accurate, current and complete. I understand that omissions or misrepresentations of the truth may result in disqualification or may result in termination of employment.I authorize
3D Medical Staffing, LLC to disclose any information gathered (including criminal background checks, employment history, credentials, references, drug screening, verification of state nursing licenses etc.) for state, federal, contractual or accreditation purposes as well as any performance appraisals, disciplinary records or skill tests. I release 3D Medical Staffing, LLC and any persons or entities providing information to 3D Medical Staffing, LLC from all liability for any damages from the disclosure of this information.I authorize
3D Medical Staffing, LLC permission to conduct an investigation to obtain information which the company thinks is necessary to determine my qualifications for employment with the company, including but not limited to, my permission to contact any former employer, or any other local, state or federal government agency, any police department, law enforcement agency or organization, or any other local, state or federal government agency, any consumer reporting agency, or any other appropriate source or individual for the purpose of gathering information, personal or otherwise, that such sources may have relating to my character, general reputation or criminal records, and I give my consent to any source to release to the company whatever information they have about me.I understand and agree that
if medical restrictions cannot be reasonably accommodated, I may not be hired, or if hired, employment may be terminated. I also understand that subject to state laws, 3D Medical Staffing, LLC reserves the right to conduct drug screening and testing for reasonable suspicion at any time during employment or pre-employment screening. Any violation of this policy may result in an applicant not being hired or adverse employment action such as immediate termination.I also understand and agree that
nothing contained in this employment application or in conducting an interview creates an employment contract between 3D Medical Staffing, LLC and myself for either employment or for any benefit. No guarantee of employment has been made to me. If employment is offered to me and a relationship is established, I understand that my employment will be termed “at will”, and that I may terminate my employment at any time and that 3D Medical Staffing, LLC also has the right to terminate my employment at any time.I also comprehend and agree to accommodate
, upon an employment offer that my work assignments, schedule and locations my change according to the staffing needs of this Company and the Clients of 3D Medical Staffing, LLC.
3D Medical Staffing, LLC reserves the right to change this policy at anytime as it requires.
Equal Opportunity Employer
3D Medical Staffing, LLC is an Equal Opportunity Employer. This agency adheres to an equal opportunity policy for all people seeking admission as client or seeking employment and for all persons employed by this agency. 3D Medical Staffing, LLC does not discriminate because of age, color, religion, military status, marital status, gender preference, sex, national origin or disability pursuant to the Civil Rights Act of 1964, the Rehabilitation Act of 1973 and the Age Discrimination Act of 1975.