Application
Personal Information
First Name
Middle Name
Last Name
Street Address
City
State
Zip Code
Home Phone
Cell Phone
SSN
Email
Specialty
Years
Specialty
Years
Specialty
Years
TX License Number
Expiration Date
Certifications
School
School Location(City, State)
Degree
Graduation Date
Emergency Contact
Emergency Contact Phone
Questionnaire
When are you available to start?
What shifts are you open to working?
Are you open to all of Texas?
No
Yes
If no, what areas of Texas will you consider?
How were you referred to Texas Select Staffing?
Have you done previous full time contract work in your profession?
No
Yes
If yes, how many contracts?
Has your professional license ever been under investigation or suspended?
No
Yes
If yes, please explain
Have you ever been convicted of a crime that would disallow your employment at a client facility?
No
Yes
If yes, please explain
Are you willing to agree to a criminal background check?
No
Yes
If hired, would you be able to present evidence of your legal right to work in the United States?
No
Yes
If requested, are you willing to take a drug and/or alcohol screen?
No
Yes
Employment History
If you have an updated resume, you may skip Employment History section.
Email resume to
resumes@texasselectstaffing.com
or fax to
866.366.9794.
Dates of Employment
to
Employer
Type of Facility
Phone Number
Location (City, State)
Position Held / Specialty
Hourly Rate
Was this a temporary contract
No
Yes
Supervisor Name and Title
Reason for leaving
Dates of Employment
to
Employer
Type of Facility
Phone Number
Location (City, State)
Position Held / Specialty
Hourly Rate
Was this a temporary contract
No
Yes
Supervisor Name and Title
Reason for leaving
Dates of Employment
to
Employer
Type of Facility
Phone Number
Location (City, State)
Position Held / Specialty
Hourly Rate
Was this a temporary contract
No
Yes
Supervisor Name and Title
Reason for leaving
Dates of Employment
to
Employer
Type of Facility
Phone Number
Location (City, State)
Position Held / Specialty
Hourly Rate
Was this a temporary contract
No
Yes
Supervisor Name and Title
Reason for leaving
Dates of Employment
to
Employer
Type of Facility
Phone Number
Location (City, State)
Position Held / Specialty
Hourly Rate
Was this a temporary contract
No
Yes
Supervisor Name and Title
Reason for leaving
Dates of Employment
to
Employer
Type of Facility
Phone Number
Location (City, State)
Position Held / Specialty
Hourly Rate
Was this a temporary contract
No
Yes
Supervisor Name and Title
Reason for leaving
References
Name
Title
Health Care Facility
Location
Phone
Name
Title
Health Care Facility
Location
Phone
Name
Title
Health Care Facility
Location
Phone
I certify that the information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I hereby authorize Texas Select Staffing to verify the information I have provided herein or attached hereto, and to contact my past employers and references concerning my work history and qualifications.
After submittal of application, please complete the appropriate skills checklist(s).
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