Career - DR. A Staffing Solutions LLC

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Employer Information

Employer:	DR. A Staffing Solutions LLC
Address:	19 Angelo Street
City/State/ZIP:	Worcester, Massachusetts 01604
Telephone:	508-365-2826

It is the policy of DR. A Staffing Solutions LLC to provide equal employment opportunities to all applicants and employees without regard to any legally protected status such as race, color, religion, gender, national origin, age, disability, or veteran status.

Applicant Information

Applicant Full Name:(Required)

Home Address:(Required)

Street Address State / Province / Region ZIP / Postal Code

Number of years at this address:(Required)

Daytime phone:

Evening phone:

Mobile phone:

Driver's License (State/Number):

Emergency Contact

Who should be contacted if you are involved in an emergency?

Contact Name:(Required)

Relationship to you:(Required)

Address:(Required)

Street Address State / Province / Region ZIP / Postal Code

Daytime phone:

Evening phone:

Job Position Applied For:(Required)

Full or Part Time?(Required)

Salary Desired:

per(Required)

Who referred you to our company?

Do you have any friends or relatives who work here? If yes, please list here:

Have you applied to our company previously?

Yes

If yes, when?

Are you at least 18 years old?(Required)

Yes

How will you get to work?(Required)

Are you willing to work any shift, including nights and weekends?(Required)

Yes

If no, please state any limitations:(Required)

If applicable, are you available to work overtime?(Required)

Yes

If you are offered employment, when would you be available to begin work?(Required)

If hired, are you able to submit proof that you are legally eligible for employment in the United States?(Required)

Yes

Are you able to perform the essential functions of the job position you seek with or without reasonable accommodation?

Yes

What reasonable accommodation, if any, would you request?(Required)

Applicant's Skills

Check those skills that you have. List any other skills that may be useful for the job you are seeking. Enter the number of years of experience and circle the number which corresponds to your ability for each particular skill. (One represents poor ability, while five represents exceptional ability.)

Skill

Years of Experience

Ability to interact with people under physical and/or emotional stress and in stressful settings. Experience in and/or knowledge of healthcare and human services, experience working with individuals in a group, nursing, and assisted living facility. Previous experience working in a residential, housekeeping, and warehouse setting.

Applicant's Skills

Skill

Years of Experience

Ability or Rating

Untitled

Applicant Employment History

List your current or most recent employment first. Please list all jobs (including self-employment and military service) which you have held, beginning with the most recent, and list and explain any gaps in employment. If additional space is needed, continue on the back page of this application.

Employer Name:

Supervisor Name:

Address:

Street Address State / Province / Region ZIP / Postal Code

Job Duties:

Reason for Leaving:

Dates of Employment (Month/Year):

Applicant's Education and Training

College/University Name and Address(Required)

Did you receive a degree?(Required)

Yes

If yes, degree(s) received:(Required)

High School/GED Name and Address(Required)

Did you receive a degree?(Required)

Yes

Other Training (graduate, technical, vocational):(Required)

Please indicate any current professional licenses or certifications that you hold:(Required)

Awards, Honors, Special Achievements:(Required)

Military Service:(Required)

Yes

Branch:(Required)

Specialized Training:(Required)

References

List any two non-relatives who would be willing to provide a reference for you.

References 1

Name:

Address:

City/State/ZIP:

Telephone:

Relationship:

References 2

Name:

Address:

City/State/ZIP:

Telephone:

Relationship:

Please provide any other information that you believe should be considered, including whether you are bound by any agreement with any current employer:

CERTIFICATION

I certify that the information provided on this application is truthful and accurate. I understand that providing false or misleading information will be the basis for rejection of my application, or if employment commences, immediate termination.

I authorize DR. A Staffing Solutions LLC to contact former employers and educational organizations regarding my employment and education. I authorize my former employers and educational organizations to fully and freely communicate information regarding my previous employment, attendance, and grades. I authorize those persons designated as references to fully and freely communicate information regarding my previous employment and education.

I HAVE CAREFULLY READ THE ABOVE CERTIFICATION AND I UNDERSTAND AND AGREE TO ITS TERMS.

APPLICANT SIGNATURE

Date

MM slash DD slash YYYY

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