Nursing Job Application | MediQuest Staffing & Homecare
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Employment Application

We are an Equal Opportunity Employer.

Emergency Contact:

Have you applied to MediQuest before?

Yes
No

Have you been employed by MediQuest before?

Yes
No

Please note, to be eligible for employment, MediQuest Staffing requires six (6) months of experience in either a nursing home or hospital setting.

Source of Referral:

Newspaper
Indeed.com
Internet
Current Employee
Friend
Other

Identity and employment eligibility will be verified as required by law.

Are you over the age of 18?

Yes
No

Have you lived in the state of Pennsylvania for the past 2 consecutive years? (Proof of residency will be required upon hire)

Yes
No

Are you a US Citizen?

Yes
No

If you are not a Citizen, do you have the legal right and necessary documents to work in the US?

Yes
No

Do you possess a valid Driver's License?

Yes
No

Do you have your own personal Transportation?

Yes
No

Can you perform the functions of the job for which you are applying, either with or without a reasonable accommodation?

Yes
No

Work Availability:

Full-Time
Part-Time
PRN
Can Work Rotating Shifts
Can Work Weekends
Days
Evening
Nights

Education

Have you graduated from High School or completed the GED equivalent?

Yes
No
Name of School:
Years Completed:
Major or Degree:
Date of Graduation:
Name of School:
Years Completed:
Major or Degree:
Date of Graduation:
Name of School:
Years Completed:
Major or Degree:
Date of Graduation:

Are you currently enrolled in school?

Yes
No

Licensure/Registration/Certification:

List all professional licenses registration, and certifications.

Lic/Reg/Cert Type:
License Number:
State:
Expiration Date:
Lic/Reg/Cert Type:
License Number:
State:
Expiration Date:
Lic/Reg/Cert Type:
License Number:
State:
Expiration Date:

Have you ever been refused professional licensure or had a license/registration suspended or revoked?

Yes
No

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

Employment History

Starting with your most RECENT EMPLOYER, please list your complete employment history.

References

Provide three work/healthcare professional references (i.e. RN/LPN/Supervisor/DON/Charge Nurse/MD as required by PA Dept of Health)

Have you ever been convicted of a felony or a misdemeanor, or have you ever plead no contest to any criminal charge?

Yes
No

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

I authorize investigation of all statements contained herein and give MediQuest Staffing and Homecare permission to contact the references listed above to give MediQuest Staffing and Homecare 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 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.

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.

I agree

(717) 560-5160

600-E Eden Road
Lancaster PA 17601

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