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APPLICATION FOR EMPLOYMENT

AMBULATORY CARE STAFFING SERVICES, INC. is an EQUAL OPPORTUNITY EMPLOYER. It is our policy to comply with all applicable state and federal laws prohibiting discrimination in employment based on race, age, color, sex, religion, national origin, or other protected classification.

Note: fields marked with a * are required.


POSITIONS APPLIED FOR
* Position Other * Wage or salary desired? * Date you can start?


IDENTIFICATION
* First Name Middle Name * Last Name
* Street * City * State * Zip
* Email * Telephone No. * Social Security No. Driver License No.
* Hours, shifts or days you are available to work *Time Preference
* Are you authorized to work in the U.S. on an unrestricted basis? YesNo
* Are you over the age of 18 years old? YesNo
* Have you been told the essential functions of the job or have you been shown a copy of the job description listing the essential functions of the job? YesNo
* Can you perform these essential functions with or without reasonable accomodation? YesNo
* Are you willing to work overtime as required? YesNo
* Have you ever been convicted of a felony? YesNo
(Conviction will not necessarily disqualify an applicant for employment.) If yes, describe conditions: (1000 characters max)


EDUCATION/TRAINING
* High School Name & Location of School
 * Major
 * Graduated 
 * Diploma/
Degree 
College/Univ. Name & Location of School
 Major
Graduated 
 Diploma/
Degree 
College/Univ. Name & Location of School
 Major
Graduated 
 Diploma/
Degree 
Other
In addition to your work history, what other job related experiences, skills, or qualifications would especially fit you for work with our company? (Note: Any non job related information provided will be disregarded and will not be considered when reviewing your application. 1000 characters max)


WORK HISTORY
* May we contact your most recent employer? Yes No
* Most Recent Employer * Name and Title of Supervisor/Manager * Telephone
* Street * City * State * Zip
$
* Starting Position * Date Started
* Starting Salary * Per
$
* Position on Leaving Date left
* Salary on Leaving * Per
* Description of Duties (1000 characters max)
* Reason for Leaving
Previous Employer 2 Name and Title of Supervisor/Manager Telephone
Street City State Zip
$
Starting Position Date Started
Starting Salary Per
$
Position on Leaving Date left
Salary on Leaving Per
Description of Duties (1000 characters max)
Reason for Leaving
Previous Employer 3 Name and Title of Supervisor/manager Telephone
Street City State Zip
$
Starting Position Date Started
Starting Salary Per
$
Position on Leaving Date left
Salary on Leaving Per
Description of Duties (1000 characters max)
Reason for Leaving


HOW DID YOU HEAR ABOUT US?
Web Site Radio (what station?)      
www.Monster.com Visited UC (which one?)   
The Columbus Dispatch Referral/Other:                
Suburban News Paper
This Week
Columbus Parent


RESUME
* Attach Resume Here Attach Cover Letter Here (Optional)
* Please use the browse button to attach your resume or cover letter in Microsoft Word or Adobe PDF format.


APPLICANT'S CERTIFICATION AND AGREEMENT

I certify the facts set forth in this Application of Employment are true and complete to the best of my knowledge. I understand that if I am employed, false statements, omissions or misrepresentations may result in my dismissal. I authorize Ambulatory Care Staffing Services, Inc. to make an investigation of any of the facts set forth in this application and release from any liability both Ambulatory Care Staffing Services, Inc. and those who supply reference information and/or verification.

I understand that employment at Ambulatory Care Staffing Services, Inc. is "at-will," which means that either Ambulatory Care Staffing Services, Inc. or I can terminate the employment relationship at any time, with or without prior notice, and for any reason not prohibited by statute. All employment is continued on that basis. I understand that no supervisor, manager or executive of Ambulatory Care Staffing Services, Inc., other than the president has any authority to alter the foregoing. Applications and resumes will be kept on file for six months.

If I am employed by Ambulatory Care Staffing Services, Inc:

I understand and agree that, if employed, I may be required to submit to an alcohol or drug screening at any time at the request of Ambulatory Care Staffing Services, Inc. I hereby consent to having the results of any alcohol or drug screening I may be required to undergo disclosed to Ambulatory Care Staffing Services, Inc.

I agree to submit to a medical examination at any time at Ambulatory Care Staffing Services, Inc. request. I hereby consent to having the results of any post-offer pre-employment or post-employment medical examination I may be required to take disclosed to Ambulatory Care Staffing Services, Inc.

I understand and agree that Ambulatory Care Staffing Services, Inc. reserves the right to establish and change any of the terms and conditions of my employment at its discretion at any time, as it deems appropriate.

I authorize Ambulatory Care Staffing Services, Inc. to release any and all information about myself, my employment record, or my employment status to any individual or organization Ambulatory Care Staffing Services, Inc. deems worthy of receiving such information. Also, I realize all parties from all liability for any damages that may result from furnishing this information.

I certify that I have read all of the foregoing, understand the same, and do hereby voluntarily agree to all of the provisions of this authorization, certification, and agreement.

READ THE ABOVE STATEMENTS BEFORE SUBMITTING THIS APPLICATION

* (By checking this box I verify that I agree to all of the above statements)
(Note: You may be required to sign a hard copy of this application upon a scheduled interview with Ambulatory Care Staffing Services, Inc.)
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