Angel Staffing, Inc.

Employment Application
Required fields are indicated by "• "
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• First Name:
Middle Name: 
• Last Name:
• Social Security #:
• Street Address/ P.O. Box:
• City:
• State:
• Zip:
• Home Phone:
• Cell Phone:
Fax:
Pager:
• E-mail Address:
• Emergency Contact Name:
Emergency Contact Address:
• Emergency Contact Phone:
• Driver's License State:
• Driver's License Number:
• Driver's License Expires: (mm/dd/yyyy)
• Are you legally authorized to work in the United States? Yes No
• How did you hear about us?
• Have you ever applied to or been employed by Angel Staffing, Inc.? Yes No
• Have you ever been convicted of any misdemeanor or felony within the last 7 years? Yes No
• Check As Appropriate:
(Certification)		 MD
PA
CNP
CRNA
RN
LVN
RT
OR TECH
CNA
Nursing Management
MKTG
HR
Internal Management
Medical Transcriptionist
Medical Records Clerk
Medical Records Tech
BMET
Medical Logistics Tech
Physical Therapy Assistant
Medical Coder
MA
• Type of Employment Desired: Per Diem
Direct Placement
Short Term Contract
Long Term Contract
• Shift Preference: 8 Day (7A - 3P)
8 Eve (3P - 11P)
8 Night (11P - 7A)
12 Day (7A - 7P)
12 Night (7P - 7A)
 

Professional Licensure/Certification
• 1. State:
• License Number:
• Expiration date: (mm/dd/yyyy)
2. State:
License Number:
Expiration date: (mm/dd/yyyy)
3. State:
License Number:
Expiration date: (mm/dd/yyyy)
  Expiration Date
CPR/BLS (mm/dd/yyyy)
ACLS (mm/dd/yyyy)
NALS/NRP (mm/dd/yyyy)
PALS (mm/dd/yyyy)
IV CERT (mm/dd/yyyy)
CCRN (mm/dd/yyyy)
TNCC (mm/dd/yyyy)
Other (mm/dd/yyyy)
 

Employment History
Clinical positions most recent first
• 1. Employed from:
 (mm/dd/yyyy)
• Employed to:
 (mm/dd/yyyy)
• Hourly Pay Rate:
 $
• Facility:
Street Address:
City:
State:
Zip:
• Facility Supervisor's Name:
• Facility Supervisor's Title:
• Facility Supervisor's Telephone Number:
• Your Title:
• Unit Assigned:
Number of Beds:
Was this a travel assignment?
 Employee
Travel Assignment
• Reason for Leaving:
Agency name:
• Area/Unit
Worked
• % of the
time
• In what
capacity?
 
2. Employed from:
 (mm/dd/yyyy)
Employed to:
 (mm/dd/yyyy)
Hourly Pay Rate:
 $
Facility:
Street Address:
City:
State:
Zip:
Facility Supervisor's Name:
Facility Supervisor's Title:
Facility Supervisor's Telephone Number:
Your Title:
Unit Assigned:
Number of Beds:
Was this a travel assignment?
 Employee
Travel Assignment
Reason for Leaving:
Agency name:
Area/Unit
Worked
% of the
time
In what
capacity?
 
3. Employed from:
 (mm/dd/yyyy)
Employed to:
 (mm/dd/yyyy)
Hourly Pay Rate:
 $
Facility:
Street Address:
City:
State:
Zip:
Facility Supervisor's Name:
Facility Supervisor's Title:
Facility Supervisor's Telephone Number:
Your Title:
Unit Assigned:
Number of Beds:
Was this a travel assignment?
 Employee
Travel Assignment
Reason for Leaving:
Agency name:
Area/Unit
Worked
% of the
time
In what
capacity?
 
 
Education Information
• What is the highest clinical degree/certification received?
• 1. School Name, City & State:
• Area of Concentration:
• Year Graduated from School:
• Degree Type:
2. School Name, City & State:
Area of Concentration:
Year Graduated from School:
Degree Type:
• Do you carry professional liability insurance? Yes No
If yes, any pending claims? Yes No

Explain:
What professional, trade, business or civic associations do you belong to?
Special accomplishments, publications, or awards?

This information is being gathered for affirmative action under Section 503 of the Rehabilitation Act of 1973. The information requested is voluntary and will be kept confidential. An applicant will not be subject to any adverse treatment for refusing to complete the questionaire.
• Race/Ethnicity
• Physical Condition
• Sex
• Veteran/U.S. Military Status
• Active National Guard Reservist
• Veteran Status
 
•  Please select, from the following, the skill/unit in which you have one year experience in the past 24 months as primary care:
BONE MARROW
BURN UNIT
CCU
CRNA
DIALYSIS
ER
GERIATRIC
L&D
MED/SURG
MICU
MOM/BABY
NICU
NURSERY
ONC
OR
OR TECH
ORTHO
PACU
PEDS
PICC
PICU
POST PARTUM
PSYCH
Rehab
SICU
SPINAL CORD
TELE
TRIAGE
TRANSPLANT
OTHER
List other acute sub specialties for which you are qualified and would like to work:
• Clinical Experience: (Number of Years)
 
Assignment Preferences
Facility:
Where do you want to work?
Describe your ideal position:
When are you available to start? (mm/dd/yyyy)
In selecting your next assignment, what is your most important consideration?
 
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8000 Character Limit (equivalent to 2 1/2 pages, 12 pt. type single spaced)
 
APPLICANT'S CERTIFICATION, AGREEMENTS AND RELEASE
PLEASE READ THE FOLLOWING CAREFULLY AND INDICATE YOUR UNDERSTANDING AND ACCEPTANCE BY SIGNING IN THE SPACE PROVIDED

RELEASE FOR BACKGROUND CHECK/ RELEASE OF RECORDS
I give the company permission to use any information in this application to enable it and its agents to verify the information contained in this application, and I authorize present and former employers, educational institutions that I have attended, credit agencies, all references, and any other persons to answer all questions asked by the company. Angel Staffing, Inc may conduct a criminal background investigation and that my employment with the company may be contingent upon the results of such investigation. I release the company, its agents, and all affiliated entities, as well as any person or institutions that provide the company with any information about me, from any and all liability whatsoever resulting from any such investigation or the disclosure of such information.

CONSENT FOR DRUG TESTING
I am willing to submit to a physical examination, including the analysis for the detection of the use of unlawful drugs or substances in accordance with applicable laws. If I receive an offer of employment at the request of the company and if one is given, i agree that my continued employment may be contingent on the results.
PROBATIONARY PERIOD AND TEMPORARY POSITION ACKNOWLEDGEMENT
I understand that I am on a probation as an employee for the first 90 days of my employment for the purposes of the Texas "Unemployment Compensation Law". I understand that if my employer discharges me for unsatisfactory work performance under the Texas "Unemployment Compensation Law". Angel Staffing, Inc will not have its account charged for any employment benefits I might be determined eligible for in the future. I understand that that if I do not contact Angel Staffing, Inc. on a monthly basis I will be considered to have voluntarily terminated my employment and that this may have an effect on benefits for which I might otherwise be eligible.

TIME SLIP POLICY
I agree, in consideration of your employing me that I will not seek or accept employment, either directly or indirectly in any capacity from any client of Angel Staffing Inc. To whom I have been assigned, for at least 30 working days after the last day of that assignment, I also agree that I will not solicit these clients on my behalf of any future employer(s). I further understand that I cannot be paid until I present a time slip signed by both the client and me to the Angel Staffing, Inc. office.

SEXUAL/ RACIAL HARRASSMENT POLICY
It is the policy of Angel Staffing, Inc. that employees have the right to work in an environment free of any form of sexual or racial harassment. If you feel that you have been sexually or racially harassed, please call your Angel Staffing Representative immediately. Any associate who advises us of possible harassment situation will not suffer repercussions due to the voicing of the complaint.

WORKER'S COMPENSATION POLICY
Angel Staffing, Inc. strives to have a safe environment for our employees to work in. In the event that you are injured while on assignment, you must call our office immediately. If you feel unable to call, please ask your supervisor to contact us. You must immediately report any injuries no matter how minor they seem. Any claims not reported immediately may be subject to denial. Angel Staffing, Inc. will work together with both the client and the employee for the proper procedure and treatment of the injury.

PATIENT TRANSPORTATION AGREEMENT
I understand that Angel Staffing, Inc. does not provide auto insurance coverage for me and that I am not to transport patients in my automobile, nor am I to drive patients in the patient's automobile without written consent from Angel Staffing, Inc.

GENERAL
In consideration of my employment and of my being considered for employment by Angel Staffing, Inc. I agree to abide by all company rules and regulations, which I understand are subject to change by the company at any time for any reason without prior notice. I also understand that if employed, I will be employed at will and employed for no definite period of time. I understand that either the company or I can terminate my employment at any time, with or without cause and with or without advance notice. I further understand that no communication, whether oral or written, by any representative of the company, at any time, can constitute a contract of employment. No representative or agent of the company other than the Director of Human Resources by either written or mutually signed agreement has the authority to enter into any agreement contrary to the foregoing.
In addition, I understand that the company and all compensation and benefits plan administrators have the maximum discretion permitted by law to administer, interpret, modify, discontinue, enhance, or otherwise administer, interpret, or change all policies, procedures, benefits, or other terms and conditions of employment.
I certify, to the best knowledge and belief, the answers given by me and the statements made by me in the application are correct and complete. I understand that any false information may result in my discharge from employment.

Confidentiality
Since the list of the company’s customers and employees are a valuable and unique asset of Angel Staffing, Inc., the applicant agrees, during or after the term of her employment, not to reveal the list, in whole or on part, or other trade secret to any person or firm, corporation, association or any other entity. Angel Staffing, Inc. may pursue any other remedies it has against the applicant for a breach or threatened breach of this condition, including the recovery of damages.
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