Application Thank you for applying for employment with Texas Select Staffing. Like many employers, Texas Select Staffing requires that you complete an application in order to be eligible for employment. Please answer all questions in this application fully and truthfully. Texas Select Staffing is an equal opportunity employer. Texas Select Staffing considers applicants for all positions without discrimination on the basis of race, color, religion, gender, national origin, age, disability, marital status, veteran status, sexual orientation or any other legally protected status. No question on this application is used for the purpose of limiting or excluding any applicant’s consideration for employment on any basis prohibited by local, state or federal law. Please complete the application below and the necessary skills checklist(s). Name* First Last Email* Phone*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Texas RN License NumberSkills InformationSpecialties*Years of Experience*Certifications*.School*School Location*Degree*Graduation Date*Emergency Contact NameEmergency Contact PhoneEmployment QuestionsAvailable Start Date* Date Format: MM slash DD slash YYYY What shifts are you open to working?*Are you open to all of Texas?*YesNoWhat areas of Texas would you consider?How were you referred to Texas Staffing?*Have you done previous full time contract work in your profession?*YesNoPlease explain any gaps in your employment history.Has your professional license ever been under investigation or suspension?*YesNoPlease ExplainHave you ever received any written reprimands, warnings, suspensions or other disciplinary action by a previous employer?*YesNoIf yes, please explain.Have you ever been discharged or asked to resign?*YesNoIf yes, please explain.Have you ever been convicted of a crime that would disallow your employment at a healthcare facility?*YesNo**Conviction will NOT necessarily bar employment. Each instance and explanation will be considered in relation to the position for which you are applying.If yes, please state the nature of the offense(s), date(s), city and state of offense(s) and disposition.Are you willing to agree to a criminal background check?*YesNoIf hired, would you be able to present evidence of your legal right to work in the United States?*YesNoHave you ever gone by or worked under a name different than listed in this application?*YesNoIf so, please explain.If requested, are you willing to take a drug and/or alcohol screen?*YesNoEmployment HistoryDo you have a resume to upload?*YesNoResume UploadIf you have an updated resume to submit, you may skip the work history section.EmployerEmployerStart Date Date Format: MM slash DD slash YYYY End Date Date Format: MM slash DD slash YYYY Employer PhoneEmployer LocationCity and StatePosition Held/SpecialtySupervisor Name and TitleWas this a temporary contract?YesNoReason for LeavingEmployerEmployerStart Date Date Format: MM slash DD slash YYYY End Date Date Format: MM slash DD slash YYYY Employer PhoneEmployer LocationCity and StatePosition Held/SpecialtySupervisor Name and TitleWas this a temporary contract?YesNoReason for LeavingEmployerEmployerStart Date Date Format: MM slash DD slash YYYY End Date Date Format: MM slash DD slash YYYY Employer PhoneEmployer LocationCity and StatePosition Held/SpecialtySupervisor Name and TitleWas this a temporary contract?YesNoReason for LeavingEmployment ReferencesSupervisors preferredName Name TitleHealthcare FacilityLocationPhoneName Name TitleHealthcare FacilityLocationPhoneName Name TitleHealthcare FacilityLocationPhoneI 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. I also authorize Texas Select Staffing to release my medical information as required by their client healthcare facilities.*I agreeI do not agreeNameThis field is for validation purposes and should be left unchanged.