Employment Registration Form – Quality Assure Health Staffing Solutions LLC

Employment Application

Please complete this form

Step 1 of 12 – Empyee Info Section

Applicant Info Section
Date
MM slash DD slash YYYY
Position Applying for?*
Name*
First Middle Last
Date of Birth*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State ZIP Code
Mobile Phone*
Home Phone*
Email Address*
Enter Email Confirm Email
Emergency Contact
Emergency Contact Name*
Emergency Contact Phone*
Emergency Contact Relationship*

Education
Education and Training*
- High School
- Vocational and Technical Education
- College
- Post Graduate
High School
High School Name*
High School Address*
Street Address City State ZIP Code
High School Diploma / High School Certificate*
Graduated
Month
Day
Year
__________________________________________________________
Vocational and Technical School Training*
Vocational and Technical School Name*
Vocational and Technical School Address*
Street Address City State ZIP Code
Vocational Graduate Certificates*
Graduated
Month
Day
Year
__________________________________________________________
College Education
Did you atted 2 or 4 year Collage
- 2 year Study
- 4 Year Study
Four-Year College Name*
Four-Year College Address*
Street Address City State ZIP Code
Associates degrees:*
Bachelor's Degree*
Graduated
Month
Day
Year
__________________________________________________________
Post Graduate School
Post Graduate School Name*
Post Graduate School Address*
Street Address City State ZIP Code
Master Degree*
Graduated
Month
Day
Year
__________________________________________________________

Licensing Information
Are You Licensed*
- Yes
- No
License Number*

Please Enter You License Number Here
State Issued*
.

Select
License Expiration Date*
Month
Day
Year
ACLS*

Yes

No
ACLS Expiration Date*
Month
Day
Year
Any Other Licenses?*

Yes

No
Descibe Which*
Please provide: License Type, License Number , State issued by; Expiration Date
Are You a Specialty Nurse*

Yes

No
If Yes Please Explain*

Resume Information

Do You have Resume?*

Yes

No
You can UPLOAD or COPY and PASTE in appropriate section of the from
How Would You Want Deliver it

Upload

Copy and Paste
Please selectv file for upload

Drop files here or

Accepted file types: txt, pdf, doc, docx, Max. file size: 1 GB.

Only .txt,.pdf, docx or doc. allowed
Paste or Type Your Resume Here Page*
Do You need second page?

Yes

No
Paste Your Resume Here Page 2

Personal References
Reference Name*
First Last
Reference Realtionship*

Reference Phone*
Reference Name*
First Last
Reference Realtionship*

Reference Phone*

Employment Status

Employment Status*

Unemployed

Employed

Employed but Looking
If You Looking for Change describe reason

Employment History

Next Step Is Previous Employment Section Click –>NEXT

Organization Name*

Enter your employer name
Superviser Name*
First Last
Phone*
Address
Street Address City State ZIP Code

Job Title /Position*

Scope of Responsibilities*
Start Date
Month
Day
Year

Still Emplyed Here*

Ys

No
End Date*
Month
Day
Year

Reason for Living*

Employment History

Here Is Previous Employment Information*

Lets Go
Organization Name*

Enter your employer name
Superviser Name*
First Last
Phone*
Address
Street Address City State ZIP Code

Job Title /Position*

Scope of Responsibilities*
Start Date
Month
Day
Year

End Date*
Month
Day
Year

Reason for Living*

Add one more?

Yes

No
Organization Name*

Superviser Name*
First Last
Phone*
Address*
Street Address City State ZIP Code

Job Title /Position*

Scope of Responsibilities*
Start Date
Month
Day
Year

End Date
Month
Day
Year

Reason for Leaving*
May We Contact your Employer*
Yes
No

Do You Need To Add One More Job?**

Yes

No
Organization Name*

Superviser Name*
First Last
Phone*
Address*
Street Address City State ZIP Code

Job Title /Position*

Scope of Responsibilities*
Start Date
Month
Day
Year

End Date
Month
Day
Year

Reason for Leaving*
May We Contact your Employer*
Yes
No

PLEASE SUBMIT FOLLOWING ITEMS AFTER COMPLETION OF THE APPLICATION
Copy of your Driver's Licensees
Accepted file types: pdf, png, txt, jpj, doc, docx, Max. file size: 1 GB.
Copy of you Social Security Card
Accepted file types: pdf, png, txt, jpj, doc, docx, Max. file size: 1 GB.
Copy of TB/PPD

Drop files here or

Accepted file types: pdf, png, txt, jpj, doc, docx, Max. file size: 1 GB, Max. files: 6.

Your Physical Report

Drop files here or

Accepted file types: pdf, png, txt, jpj, doc, docx, Max. file size: 1 GB, Max. files: 6.

( if applicable)
Your Physical Report

Drop files here or

Accepted file types: pdf, png, txt, jpj, doc, docx, Max. file size: 1 GB, Max. files: 6.

( if applicable)
CPR Card
Accepted file types: pdf, png, txt, jpj, doc, docx, Max. file size: 1 GB.
Copy of your Registration/License/Certification
Accepted file types: pdf, png, txt, jpj, doc, docx, Max. file size: 1 GB.
Registration/License/Certification/Number

Additional Comments if Needed
Are You Human

Job Seekers

Employment Application

Step 1 of 12 – Empyee Info Section

Applicant Info Section

Emergency Contact

Education

High School

Vocational and Technical School Training*

College Education

Post Graduate School

Licensing Information

Resume Information

Personal References

Employment Status

Employment History

Next Step Is Previous Employment Section Click –>NEXT

Employment History

Job Seekers

(212) 843-9222

Phone

(212) 843-9214

Fax

26 Broadway, Suite 934, New York, NY 10004

Address

Email

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