Employment Position
Select the position you're applying for:
How did you hear about this position?
Select the days you're available for work:
Select the hours you're available for work:
Personal Information
Have you ever applied to or worked for Patient-Centered Care Staffing Agency before? If so, when?
Do you have any friends, relatives, or acquaintances working for PCCSA? If so, state name & relationship.
Are you 18 years of age or older?
Are you a U.S. citizen or approved to work in the United States?
What document can you provide as proof of citizenship or legal status?
Will you consent to a mandatory controlled substance test?
Do you have any condition which would require job accommodations? If so, please explain.
Have you ever been convicted of a criminal offense (felony or misdemeanor)? If so, please state the nature of the crime(s), when and where convicted and disposition of the case:
Job Skills/Qualifications
Please list below the skills and qualifications you possess for the position for which you are applying
Education
Vocational School/Specialized Training
Military
Are you a member of the Armed Services? What branch of the military did you enlist? What was your military rank when discharged? How many years served?
Previous Employment:
Employer Name, Job Title, Supervisor Name, Employer Address, Telephone, Dates Employed, Reason for Leaving
Previous Employment:
Employer Name, Job Title, Supervisor Name, Employer Address, Telephone, Dates Employed, Reason for Leaving
Previous Employment:
Employer Name, Job Title, Supervisor Name, Employer Address, Telephone, Dates Employed, Reason for Leaving
References:
Please provide 3 personal and professional references.
At-Will Employment
- The relationship between you and the Patient-Centered Care Staffing Agency is referred to as "employment at will." This means that your employment can be terminated at any time for any reason, with or without cause, with or without notice, by you or the Patient-Centered Care Staffing Agency.
- No representative of Patient-Centered Care Staffing Agency has authority to enter into any agreement contrary to the foregoing "employment at will" relationship.
- You understand that your employment is "at will," and that you acknowledge that no oral or written statements or representations regarding your employment can alter your at-will employment status, except for a written statement signed by you and either our Executive Vice-President/Chief Operations Officer or the Company's President
By typing your name below, you are verifying that all of the above information is correct and authentic.
