* = Required Information

Position(s) Applied for *   Date of Application *  
APPLICANT INFORMATION
Last Name *  First *  M.I. 
Street Address *  Social Security # * 
City *  State *  ZIP * 
Telephone Number(s) What is the best time to contact you at home? 
Date Available *  Desired Salary *  E-mail Address * 
Are you prevented from lawfully becoming employed because of Visa or Immigration Status? YesNo
Have you ever been employed with us before? YesNo If yes, give date 
Can you travel if a job requires it? YesNo
Can you perform the essential functions of the job, for which you are applying, either with or without reasonable accommodation? YesNo
Do you have professional liability insurance? YesNo
If yes, give Carrier Name:  Policy Number:  Exp. Date: 
Do any of your friends or relatives work here? YesNo If yes, state name and relationship 
Have you ever been convicted of a crime? YesNo If yes, explain 
A criminal record does not constitute an automatic bar to employment and will be considered only as it related to the job in question.
Availability to work (check all that apply)
Full time (Please select shift. 123) Temporary (indicate dates available)  
How did you learn about us?
Advertisement Internet Advertisement Friend Inquiry Employment Agency Relative
Other
 
 
EDUCATION
School Name and Address Course of Study Number of Years Completed Diploma/Degree
High School *
Undergraduate College
Graduate/Professional
Other (Specify)
ADDITIONAL INFORMATION
Do you have a current, valid license/certification? YesNo
License/Cert. Type  State  License No.   Exp. Date 
License/Cert. Type  State  License No.   Exp. Date 
License/Cert. Type  State  License No.   Exp. Date 
CPR  Exp. Date 
ACLS  Exp. Date 
Has your professional license, certification or registration ever been subject to disciplinary action by any state board or body, such as by reprimand, suspension, revocation, consent order, voluntary surrender or fines? YesNo
Are you currently working under a consent order or with a restricted license from any state licensing body or board? YesNo
Are you aware of any pending complaints or investigations against your professional license, certification or YES NO registration in any state to the best of your knowledge? YesNo
State any additional information you feel may be helpful to us in considering your application, including any other training or special skills that you possess related to the job.

PREVIOUS EMPLOYMENT
List your past work experience beginning with the most recent.
Employer * 
Dates Employed
From* To*
Work Performed *
Address * 
City/State * 
Starting Salary $* Ending Salary $*
Telephone Number * 
Job Title *  Reason for Leaving * 
Supervisor *  May we contact for a reference? * Yes * No
 
Employer 
Dates Employed
From To
Work Performed
Address * 
City/State 
Starting Salary $ Ending Salary $
Telephone Number 
Job Title  Reason for Leaving 
Supervisor  May we contact for a reference?YesNo
 
Employer 
Dates Employed
From To
Work Performed
Address * 
City/State 
Starting Salary $ Ending Salary $
Telephone Number 
Job Title  Reason for Leaving 
Supervisor  May we contact for a reference?YesNo
We consider applications for all positions without regard to race, color, religion, creed, sex, national origin, disability, sexual orientation, citizenship status or any other legally protected status.
PERSONAL REFERENCES
List name and telephone number of three business/work references who are NOT related to you and are NOT previous supervisors. If not applicable, list three school or personal references who are not related to you.
NAME TELEPHONE NUMBER OF YEARS KNOWN
* * *
DISCLAIMER AND SIGNATURE

I certify that my answers are true and complete. I authorize LJD to request and receive any information and records concerning me, including, but not limited to criminal history, driving, employment, military, civil and educational data and reports, from any individuals, corporations, partnerships, associations, institutions, schools, governmental agencies and departments, courts, law enforcement and licensing agencies, consumer reporting agencies, references and any other entities, including my past and present employers.

I understand that LJD has the right to rescind any offer of employment that may have been made, as well as the right to terminate my employment, based on the information received.

I understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with LJD is of an “at will” nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release. I agree, if I'm hired by LJD, to keep my credential JCAHO and OSHA in-service requirements current and to abide by the policies, procedure and supervisor of the client to which I am assigned and those of LJD Healthcare Staffing.