Position I am applying for:
Have you applied to MQS before?
Have you been employed by MQS before?

First Name:

Last Name:

Middle Initial:

Current Address Line1:

Current Address Line2:

City:

State:

Zip Code:

County:

Work Phone:

Home Phone:

Cell Phone:

E-mail Address:
Source of Referral:

Newspaper

Job Service

 Internet

Yellow Pages

MQS Employee:

Other:

Are you over the age of 18?

Are you a US Citizen?

If you are not a US Citizen, do you have the legal right and necessary documents to work in the US? - Identity and employment eligibility will be verified as required by law.
School District of Residence

Township of Residence

Do you posess a Driver's License?

State:

Driver's License Number

Do you have your own transportation?

Languages Spoken in addition to English:

Can you perform the functions of the job for which you are applying, either with or without a reasonable accommodation? Yes     No

Work Availability:

Current Salary: $   Minimum Salary: $   Date of available work:

Full-time
Part-time
PRN
Hours Available		 Can Work Weekends
Can Work Rotating Shifts
Days
Evenings
Nights

Emergency Contact:

In case of an emergency, please contact:
Name: Phone: Address:

Education:

Have you graduated from High School or completed the GED equivalent? Yes     No

List your highest degree first.

Major Degree School Graduation Date

Are you currently enrolled in school? Yes     No
Major:

Check last level of school completed:

Years of college completed: Undergraduate: Freshman Sophomore Junior Senior
  Graduate: 1st year 2nd year 3rd year 4th year

Licensure/Registration/Certification:
List all professional licenses, registrations, and certifications. Additional space is available at the end of the application.

Lic/Reg/Cert Type License Number State Expiration Date

Please indicate which of the following credentials you currently hold:

CPR: Yes   No  -> Expiration Date:
ACLS: Yes   No  -> Expiration Date:
NALS: Yes   No  -> Expiration Date:
PALS: Yes   No  -> Expiration Date:
Other:  Expiration Date:
Other:  Expiration Date:

I have received the following immunizations or titers:
Rubella Immunization Titer Date:
Rubeola Immunization Titer Date:
Varicella Titer or documented history Date:
Hepatitis B Vaccination Delination Date:
Dates:   

Do you have any pending restrictions and/or suspensions on your current professional license/registration that would restrain you from performing in this position? Yes    No

Have you ever been refused professional licensure, or had a license / registration suspended or revoked? Yes    No
If yes, please explain:

Employment History:
Start with your most recent employment, record of all employment and reasons for periods of unemployment. Additional space is available at the end of the application.

Company Name Address City State Zip Code (Area Code) Phone
Company Email Address:
Type of Business Supervisors Name, Title, and Phone Number Date Employed Date Left
Title and Duties: Reason(s) for leaving:
If your employment record exists under another name, please specify:
Salary: $
May we contact this employer?



Company Name Address City State Zip Code (Area Code) Phone
Company Email Address:
Type of Business Supervisors Name, Title, and Phone Number Date Employed Date Left
Title and Duties: Reason(s) for leaving:
If your employment record exists under another name, please specify:
Final Salary: $
May we contact this employer?



Company Name Address City State Zip Code (Area Code) Phone
Company Email Address:
Type of Business Supervisors Name, Title, and Phone Number Date Employed Date Left
Title and Duties: Reason(s) for leaving:

If your employment record exists under another name, please specify:
Final Salary: $

May we contact this employer?


References

Provide three work related supervisory references with complete mailing address:

Name Occupation
or Title		 Firm Name and Address
(Include City, State, and Zip)		 (Area Code)
Phone		 Years Known
Reference # 1 Email:
Name Occupation
or Title		 Firm Name and Address
(Include City, State, and Zip)		 (Area Code)
Phone		 Years Known
Reference # 2 Email:
Name Occupation
or Title		 Firm Name and Address
(Include City, State, and Zip)		 (Area Code)
Phone		 Years Known
Reference # 3 Email:

Additional information/comments:

Have you ever been convicted of a felony or a misdemeanor, or have you ever plead no contest to any criminal charges? Yes    No
Provide date, city, state and an explanation for all yes responses. Use additional space if necessary.

Criminal conviction is not an absolute bar to employment but will be considered in relation to specific job requirements.

Certification and Agreement

I certify that the facts contained in this application are true and complete to the best of my knowledge. I understand that, if employed, falsified statements on this application shall be grounds for dismissal.

I authorize investigation of all statements contained herein and give MediQuest Staffing permission to contact the references listed above to give MediQuest Staffing all information they may have, personal and professional, and release all parties from liability for damage that may result from furnishing same to MediQuest Staffing.

I understand that I will be required to provide verification of licenses, certifications and other essential credentials contained in this application.

I agree that if I am employed by MediQuest Staffing, I must abide by the information in the Employee Policy Handbook.

I understand that my employment is contingent upon proof of my eligibility to work in the United States, verification of all licenses and certifications necessary for my position, satisfactory results of my pre-employment criminal background check, reference checks, and drug screen.

I understand that if I am employed with MediQuest Staffing, Inc., my employment will be at-will. As such, it can be terminated by me or by MediQuest Staffing with or without advance notice, at any time, and for any reason not prohibited by law.

  I Agree

By checking "I Agree" and submitting this employment application, I acknowledge that the information I have provided is accurate, that I have read the certification and agreement, and that I agree to abide by its terms.



Another Site Designed by Schell's Web Design