HealthStaff Alternatives

Register Online Registration Form


Name:
	Last	First	M.I.

Address:
	Street


	City	State	Zip

Telephone:
	Home	Work

	Cell	Pager

Home E-mail:
Emergency Info:
	Contact Name	Daytime Phone
How did you hear about us?

Type of work you are seeking:
	Full-time contract	Part-time contract
	Full-time Direct Hire	Part-time Direct Hire
If part-time, indicate number of hours per week preferred. Any schedule limitations?

________________________________________________________

EDUCATION

College:

Name

Grade Completed

Degree Earned

High School:

Name

Grade Completed

Other:

Name

Grade Completed

Degree Earned

Honors Received:

Licensure

State	License	Professional License #	Expire Date

Certifications

State	Certification	Expire Date

________________________________________________________

BACKGROUND

It is legally necessary for this Company to know if you have ever been convicted or if charges are pending against you for any type of felony. It is also legally necessary for this Company to know if you have ever been convicted, if charges are pending against you or if you have been held civilly liable for any act of dishonesty or a breach of trust including misdemeanors, violations of municipal ordinances, etc. Examples of dishonesty or a breach of trust include shoplifting, issuing worthless checks, burglary, check kiting, any type of theft, etc. Participation in "first offender," "pretrial diversion," or other similar programs (even if the charges are later dismissed) or convictions resulting in a suspended sentence must be explained. Traffic violations are not being included in your answer. If you are uncertain as to whether the violation should be explained please list. A "yes" answer to either of the questions below will not automatically disqualify you from employment but will require further review. A dishonest answer or an omission will result in refusal to hire or, if hired, immediate dismissal. If you are applying for a position based in Illinois, you do not have to list pending charges.
Have you ever been convicted or are charges pending against you for any type of felony?
	Yes	No
Have you ever been convicted, held civilly liable, participated in a "first offender," "pretrial diversion" or similar program, or are charges pending against you for any act of dishonesty or breach of trust?
	Yes	No
Have you ever had disciplinary action taken against any license, or are you currently the subject of a report or investigation?
	Yes	No

If you have answered yes to any of the three questions above, explain (including date, nature and place of the offense, disposition of the case and your name then, if different):

(A criminal conviction is not an automatic bar to employment.)
Are you able to perform the basic funcitons of the position for which you are applying with or without reasonable accomodations?
	Yes	No
Do you have the legal right to reside and work in this country?
	Yes	No
Do you possess a valid driver's license?
	Yes	No
Do you write or speak any languages other than English?
	Yes	No
List Languages:
________________________________________________________

EMPLOYMENT PREFERENCES

What are your short and long term employment goals?

What does the opportunity you're seeking look like?

What is your pay requirement/expectation?
Full-time:		Contract:
	Annual		Hourly

Relocation:	Yes	No
If Yes:	Instate	Out state

________________________________________________________

EMPLOYMENT HISTORY

List employers and positions, most recent first, or attach resume and
complete starred fields. * Required Field

Company 1
	* Company:
	Address:
	Industry:
	* Position:
	* Dates of Employment:
	Supervisor name:
	Telephone:
	Major responsibilities:
	Accomplishments:
	Technical skills used on the job:
	Starting salary:
	* Ending salary:
	* Reason for leaving company:

________________________________________________________

Company 2
	* Company:
	Address:
	Industry:
	* Position:
	* Dates of Employment:
	Supervisor name:
	Telephone:
	Major responsibilities:
	Accomplishments:
	Technical skills used on the job:
	Starting salary:
	* Ending salary:
	* Reason for leaving company:

________________________________________________________

Company 3
	* Company:
	Address:
	Industry:
	* Position:
	* Dates of Employment:
	Supervisor name:
	Telephone:
	Major responsibilities:
	Accomplishments:
	Technical skills used on the job:
	Starting salary:
	* Ending salary:
	* Reason for leaving company:

EQUAL EMPLOYMENT OPPORTUNITY POLICY

Equal Employment Opportunity has been and continues to be both policy and practice at HealthStaff Alternatives, LLC (HSA). The company provides equal employment opportunity to all employees and applicants without regard to age, race, creed, color, religion, national origin, sex, disability, veteran status, marital status, or any other protected status in accordance with applicable federal, state and local laws.

This policy governs all areas of employment at HSA, including recruiting, hiring, training, assignments, promotions, compensation, benefits, discipline and terminations.

In addition, HSA does not discriminate against any temporary employee or applicant in work assignments, does not invite or honor discriminatory job orders or requests by clients, and does not "code" applications or other documents to record the status of any applicant or employee.

Any employee who violates this Policy will be subject to discipline, up to and including the possibility of discharge.

________________________________________________________

CONFIDENTIALITY

Employee acknowledges that certain confidential information may be transmitted or disclosed to Employee by HealthStaff Alternatives or its Client in connection with Employee's performance of this Agreement. Confidential information includes but is not limited to methods, concepts, computer programs, compilations, data, documentation, marketing plans, inventions and new ideas, client lists and all other information originated by or peculiarly within the knowledge of HealthStaff Alternatives or its Client which is generally not known to others. Generic knowledge or information publicly known that is generally employed by the trade shall not be deemed part of the confidential information. The confidential information constitutes the valuable trade secrets of Professional Alternatives or its Client. Employee shall not, at any time, directly or indirectly, use, copy, reveal, report, memorialize, publish, duplicate or otherwise disclose to any third party in any way whatsoever any confidential information without the written consent of HealthStaff Alternatives, consent shall be exercised in the sole discretion of HealthStaff Alternatives. Employee shall receive, maintain and use the confidential information in the strictest of confidence and shall use best efforts to keep the confidential information strictly confidential and to prevent disclosure thereof. Upon termination of the employment relationship, Employee shall return all confidential information defined herein in Employee's possession and control to HealthStaff Alternatives.

________________________________________________________

FAIR COMPETITION

Employee agrees that for a period of 12 months following the completion of your assignment with the Client for any reason you will not seek or accept, directly or indirectly, work or employment with the Client, whether as a temporary employee, an employee on the Client's payroll or another entity's payroll, a consultant, an independent contractor or otherwise, unless such employment is arranged by Professional Alternatives or Professional Alternatives gives its advance written permission to such assignments or employment. In the case of an offer of employment by the Client, a placement fee will be payable to Professional Alternatives from the Client, unless some other agreement is reached between HealthStaff Alternatives and the Client.

________________________________________________________

APPLICANT AUTHORIZATION AND CONSENT
FORM FOR EMPLOYMENT REFERENCES
AND EDUCATION VERIFICATION

I have applied for employment with HeathStaff Alternatives LLC (HSA). As part of that application process, I have been requested to provide references and information regarding my background from former employers, civilian or military, and educational institutions and courts.

The purpose and procedures used in this investigation have been fully described to me and I completely understand the reasons and potential uses of such investigation. I authorize HSA to use any and all information acquired to make decisions regarding my employment, which may be disclosed to third parties.

I understand and agree that if any material facts are discovered which differ from those facts stated by me on my employment application, at my interview, or at any time prior to my commencing employment at HSA (if I am offered a position with HSA), I will not be offered the job. Furthermore, I understand and agree that if material facts are later discovered which are inconsistent with or differ from facts I furnished before taking the job, that will be grounds for discipline up to and including the possibility of immediate discharge.

I hereby authorize and request my references, former employers and educational institutions which I attended to provide to HSA the information it requests about me, my employment and my educational background. I release and discharge HSA, its employees and agents, and all persons or organizations which may provide information regarding me in accordance with this authorization, of and from any liability arising out of such inquiries by HSA or any response to such inquiry.

________________________________________________________

EMPLOYEE NOTIFICATIONS

HSA retains the right to terminate an employee at any time for any reason not prohibited by law. An employee has the right to resign employment at any time for any reason (subject to two weeks notification to HSA). These mutual rights constitute our employment at will policy.
This Employment Application does not constitute a contract of employment between the Employee and HSA. Further, any understanding or agreement between an employee and HSA must be in writing and executed by the employee and a HSA officer.

Resume Attachment:

Please enter your initials in this box to indicate that you have answered all the questions correctly to the best of your knowledge.

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