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STAT Staffing, Inc. – Quick Employment Application
Required fields are indicated by "•"
• 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
Who can we thank for your referral?
• Have you ever applied to or been employed by STAT 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)		 CNA
LPN
RN
PT
PTA
SLP
OT
COTA
CHHA
OTHER
Type of Employment Desired: Travel (13-26 weeks)
Per Diem
Direct Placement
Fast Response (4 week only)
Type of Shifts: 8 Hour Shifts
12 Hour Shifts
10 Hour Shifts
Other
Shift Preference: DAY
NOC
EVE
 
 
• Please select, from the following, the skill/unit in which you have one year experience in the past 24 months as primary care:
ER
ICU
OBGYN
OR
PICU
TELE
PEDS
L & D
MS
PACU
PSYCH
THERAPY
PRIV DUTY
SCHOOL
SNF
OTHER
 

SEXUAL/RACIAL HARASSMENT POLICY
It is the policy of STAT 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 STAT Staffing, Inc. Representative immediately. In the event that you are unable to contact them, please feel free to contact our corporate office. Any associate who advises us of a possible harassment situation will not suffer repercussions due to the voicing of the complaint.

WORKER’S COMPENSATION POLICY
STAT Staffing, Inc. strives to have a safe environment for our employees to work in. In the event you are injured while on an 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 may seem. Any claims not reported immediately may be subject to denial. STAT Staffing, Inc. will work together with both the client and the employee for the proper procedure and treatment of the injury.

By clicking "Continue" I agree that:
I have read and fully understand the questions asked in this application and that all answers given by me are true, accurate, and complete. I also understand that the omission, concealment, or misrepresentation of any fact on this application or during any interview for employment and be cause for my immediate dismissal from employment.

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 institution I have attended, credit agencies, all references, and any other persons to answer all questions asked by the Company, STAT 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 provides the Company with any information about me, from any and all liability whatsoever resulting from any such investigation or the disclosure of such information.

In consideration of my employment and of my being considered for employment by STAT 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 an employee at will and employed for no definite period of time. I understand that either the company or I can terminate my employment at an 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 for employment for any specific period of time or to make 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 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.

I agree, inconsideration of your employing me, that I will not seek or accept employment, either directly or indirectly in any capacity from any client of STAT 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 nor on 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 STAT Staffing, Inc. office.

I understand that STAT 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 STAT Staffing, Inc..