Brighten Health Group

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Notice to Applicants:

All Staffing Inc. is an equal opportunity employer. We are committed to providing employment opportunities to you and all other persons without regard to race, color, religion, sex national origin, marital status, citizenship, age, disability or veteran status. Anyone requiring a reasonable accommodation for the application and/or process should notify the Human Resource Department.

First Name:

Middle Initial:

Last Name:

Social Security Number:

Current Address:
Street:

City:

State:

ZIP:

County:

Local Tax Jurisdiction:

Telephone Number:

Years at Current Address:

Previous Address:
Street:

City:

State:

ZIP:

Position applying for:

Date Available to Start:

Work Schedule Desired:

If Part-time, Specify Your Available Hours By Day:
Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Check all shifts for which you are available:
1st Shift
2nd Shift
3rd Shift
4th Shift
Are you available to work overtime?
Do You Have a Legal Right to Work?
If Required, Do You Have a Driver’s License?
Have you worked with us before?
If Yes, list position / dates / location:

List any friends or relatives working with us now:

Who referred you For This Opening:

Have You Ever Been Convicted of a Felony?
If Yes, please explain (This will not automatically bar you from employment)

Have You Ever Been Bonded?
If Under 18, Can You Furnish a Work Permit?

EDUCATION

High School (List Name, City, State)

Did you Graduate?
If no, List Years or Credits Completed

College (List Name, City, State)

Major:

Did you Graduate?
If no, List Years or Credits Completed
List Degree/Certificate

Other (List Name, City, State)

Major:

Did you Graduate?
If no, List Years or Credits Completed
List Degree/Certificate

EMPLOYMENT

List most current first
#1
Employment dates (Mo/Yr)
From To
Employer (Name, Address, Phone):

Starting Pay:

Ending Pay:

Reason for Leaving:

Job Title:

Immediate Supervisor (Name & Title):

Give a Brief Description of Job Duties

#2
Employment dates (Mo/Yr)
From To
Employer (Name, Address, Phone):

Starting Pay:

Ending Pay:

Reason for Leaving:

Job Title:

Immediate Supervisor (Name & Title):

Give a Brief Description of Job Duties

#3
Employment dates (Mo/Yr)
From To
Employer (Name, Address, Phone):

Starting Pay:

Ending Pay:

Reason for Leaving:

Job Title:

Immediate Supervisor (Name & Title):

Give a Brief Description of Job Duties

ADDITIONAL INFORMATION

List equipment and/or office machines, computer software, special sraining, licenses and/or certificates that you possess, have experience with, or qualify you to perform job-related functions in the position for which you are applying.

Emergency Contact:
Name

Relationship

Day Phone

Evening Phone

APPLICANT STATEMENT

I certify that the information provided by me on this application is true and complete to the best of my knowledge. I understand that any material omission or false statement can result in the termination of my employment, whenever it is discovered.

I give All Staffing, Inc. or my Worksite Employer, their agents and assigns, the right to contact and obtain information from all references, employers, educational institutions and to otherwise verify the accuracy of the information provided in this application. I hereby release from all liability All Staffing, Inc. or my Worksite Employer, their agents and assigns, for seeking, gathering and using such information. I also release from all liability all persons, corporations or organizations for furnishing such information.

Unless I am a contractual employee, I understand that I am an at-will employee and am free to resign at any time and All Staffing Inc., or my Worksite Employer, their agents and assigns, is free to terminate my employment at any time with or without reason or notice. This application does not constitute an agreement or contract for employment for any specified period or duration. I understand that no representative of All Staffing, or my Worksite Employer, other than an authorized officer, has the authority to make at assurances to the contrary.

In consideration of the Company entertaining this application for employment, I understand that any and all disputes or claims arising from this application or subsequent employment shall be resolved pursuant to the rules and procedures of the Dispute Systems. In All disputes or claims shall first be submitted to mediation, and if not resolved, to final and binding arbitration pursuant to the provisions of the Federal Arbitration Act. I understand that my right to a trial by jury and appeal is waived.

By clicking the "Submit" button below, I agree to these terms and conditions.