Work Time Available - Check any that apply.
Full TimePart TimeTemporaryStudent

Are you a U.S. citizen or have EAD permit (Form I-766) to work in U.S.?
YesNo

Have you ever been convicted of a felony, misdemeanor involving any violent act, use or possession of a weapon or act of dishonesty for which the record has not been removed?
YesNo

If Yes, please briefly explain:

Qualifications for Position?

Please briefly outline main responsibilities:

Last Employer's Address:

Provide three persons who have knowledge of your work performance within the last four years. Include professional references only, not family or friends.

Reference One - Name including Phone:

Reference Two - Name including Phone:

Reference Three - Name including Phone:

I certify that I have not purposely withheld any information that might adversely affect my chances for hiring. I attest to the fact that the answers given by me are true & correct to the best of my knowledge and ability. I understand that any omission (including any misstatement) of material fact on this application or on any document used to secure can be grounds for rejection of the application or, if I am employed by this company, terms for my immediate expulsion from the company.

Electronic signature in all upper case text:

I permit Assured Nursing, Inc. to examine my references, record of employment, education record, and any other information I have provided. I authorize the references I have listed to disclose any information related to my work record and my professional experiences with them, without giving me prior notice of such disclosure. In addition, I release the company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such examination or revelation.

Electronic signature in all upper case text:

Contact AgreementYou authorize Assured Nursing, Inc. to text, call, or email you regarding this employment application. Additionally, if applicable, you will provide any résumé or other viable documents below before submitting this employment application.