MedFirst Staffing

Thank you for your interest in MedFirst Staffing. The first step for you in joining our team is to complete and submit this on-line employment application. There is no obligation for you to work with MedFirst if you simply submit your application. However, we will know your interests, including desired locations, should you decide to work with us.

In order to process your application, please answer all questions. If you have a current resume, please send it as an attachment in a separate e-mail to us at Complete your name and Social Security number exactly as they appear on your Social Security card. This application was designed to be used with several types of job positions, so some questions may not be completely applicable to the job position you are seeking. However, we ask that you answer all questions.

ALL FIELDS ARE REQUIRED!

Date: 
Social Security #: --
How did you hear of us?: 
First Name: 
Middle Initial: 
Nickname: 
Last Name: 
Email Address: 
Address: 
Apartment:
City: 
  State:  
 Zip: 
Home Phone:  () -
    Alt Phone:  () -
Emergency Phone:  () -
Notify In Case of Emergency: 
Employment Interest: Full Time Part Time Temporary
Temporary to Hire Direct Hire
Availability: Days   Mon Tues Wed
  Thurs Fri Sat Sun
Available Shifts   1st 2nd 3rd
Position Desired:    1st Choice:  
   2nd Choice: 
Have you ever applied with or been employed with MedFirst before?     Yes     No If Yes, give date: 

EDUCATIONAL DATA
School Name, City
and State
for Each School		 # of Years
Completed		 Month/
Year
Graduated		 Diploma,
Degrees
Received
High School
College or Trade
Other

LICENSURE
State License Exp. Date

CERTIFICATIONS
Choose One:  Certified Registered Registry Eligible
Other
Certificate/Registration and Number:
Exp. Date:
Has your professional license or certificate ever been investigated or suspended?     Yes No
If yes, please explain:
Have you ever been named as a defendant in a professional liability action?     Yes No
If yes, please explain:
Have you ever been convicted of a crime other than a minor traffic violation?     Yes No (Driving under the influence is not considered a minor traffic violation.)
If yes, please explain:
Can you submit verification of your legal right to work in the U.S.?     Yes No
If no, please explain

EMPLOYMENT RECORD

PREVIOUS JOBS: Account for all time periods including unemployment, self-employment and military service. Please document reasons for periods you were not employed. Please begin with your current or most recent employment.

Facility/Employer:
Dept./Unit:
Street Address:
City:
State:
Zip:
Dates employed:  
From:
To:
Reason for leaving:
Position held:
Specialty:
Supervisor’s name and title:
Phone:
Salary:  
Starting:
Ending:
Job Duties:
Travel Assignment?     Yes No
Staffing Agency?     Yes No
Facility/Employer:
Dept./Unit:
Street Address:
City:
State:
Zip:
Dates employed:  
From:
To:
Reason for leaving:
Position held:
Specialty:
Supervisor’s name and title:
Phone:
Salary:    
Starting:
Ending:
Job Duties:
Travel Assignment?     Yes No
Staffing Agency?     Yes No
Facility/Employer:
Dept./Unit:
Street Address:
City:
State:
Zip:
Dates employed:  
From:
To:
Reason for leaving:
Position held:
Specialty:
Supervisor’s name and title:
Phone:
Salary:  
Starting:
Ending:
Job Duties:
Travel Assignment?     Yes No
Staffing Agency?     Yes No
Facility/Employer:
Dept./Unit:
Street Address:
City:
State:
Zip:
Dates employed: From:
To:
Reason for leaving:
Position held:
Specialty:
Supervisor’s name and title:
Phone:
Salary:  
Starting:
Ending:
Job Duties:
Travel Assignment?     Yes No
Staffing Agency?     Yes No
Other names under which you have been employed (i.e. maiden name):
Please explain any additional qualifications, education or training, including medication courses:
Are you CPR certified?    Yes No Date:
Source of training:
APPLICANT’S STATEMENT

I understand that misrepresentation, omission of facts, or incomplete information requested may result in my not being considered for employment.

I certify all statements given herein are true and complete and, if employed, I understand that false and misleading statements given in my application or interview(s) may result in dismissal, regardless of the time they are discovered.

I authorize investigation of all statements contained in this application and any attachments for employment including contact of my previous employers, verification of education, a criminal background check, driver’s license history and any other information as may be necessary in arriving at an employment decision. I hereby release the Company and all persons and organizations from any and all claims and liability of any kind arising from such investigation or the supplying of information as part of such process.

I understand that employment is conditional upon my passing a drug screen. I agree to submit to a screening test prior to employment and, if employed, from time to time during the course of my employment whenever requested by the Company.

If employed, I understand that my employment is for no definite period. I understand and agree that any company documents including written personnel policies or employee handbooks now in effect, or to be issued at any later time, are not contracts of employment for a definite duration and that my employment is at-will, which means that either I or the Company can terminate the employment relationship at any time for any reason. I further understand that only the President of the Company has any authority to enter into any agreement for employment with me for any specified period of time; that such agreement must be in writing and signed by the President; and that all other statements to the contrary, whether oral or written, are of no force and effect.


ELECTRONIC SIGNATURE

This employment application form has been provided to you electronically. You have a right to receive this document in paper format. By clicking on the "I Agree" button, you represent and warrant that the information you have provided is true and accurate and that you agree to the electronic transmission of this information. You also agree that you have read and understood the above acknowledgment and agree to its terms. You can withdraw consent to electronic delivery at any time. If you want to withdraw consent to electronic delivery or if you have any questions about the application process or opportunities available with us, please contact us. You further agree that your clicking on the "I Agree" button constitutes an electronic signature as defined by applicable federal and state laws, including but not limited to the Electronic Signatures in Global and National Commerce Act and the South Carolina Uniform Electronic Transactions Act.



37 Villa Road, Suite 213 · Greenville, SC 29615 · 1-888-421-0395