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CANSTAFF EMPLOYMENT SERVICES EMPLOYMENT APPLICATION
Date: __________________
Full Name (print): _________________________________________________________________________
Address: ________________________________________________________________________________
City: ____________________________________ State: ______________________ Zip: ________________
Phone #: __________________________________ Cell #: _______________________________________
Position Desired: _______________________________________ Full Time Part Time (Circle all that apply)
Emergency Contact (Name and Phone Number): ________________________________________________
SHIFTS AVAILABLE TO WORK: Days Swing shift Graveyard (Circle all that apply) EDUCATION: High School (Circle One) Diploma Awarded GED Completed Not Completed School/Location: ____________________________________________ Last Year Attended: _____________
College/Trade School (Circle One) Bachelors Associates Certificate Not Completed School/Location: ____________________________________________ Last Year Attended: _____________ School/Location: ____________________________________________ Last Year Attended: _____________ School/Location: ____________________________________________ Last Year Attended: _____________
EXPERIENCE/SKILLS: (Circle all that apply)
OFFICE SKILLS MEDICAL SKILLS SOFTWARE SKILLS LABOR/CONSTRUCT. Typing _____wpm Phone Triage IBM Fork Lift Ten Key Vitals Macintosh Welding / Fabrication Multi-line Phones ___# lines Patient History Windows Warehouse Appointment Scheduling Injections Medical Manager Heavy Lifting Medical Records Venipuncture Medic Drywall Word Processing/Spreadsheet Phlebotomy Lytec Framing Medical Transcription IV Therapy Nextgen Painting (Interior/Exterior) Accounts Receivable Blood Counts Reynolds & Reynolds Roofing Accounts Payable Urinalysis Poorman Douglas Concrete Payroll Holter Monitor Quickbooks Production / Assembly Collections Limited X-Ray Word Manufacturing Cashier Radiology Tech Excel MT or MLT Access Languages: EKG and/or EEG CADD LICENSE/CERTIFICATION: ____________________ RN #______________________ ____________________ LPN # ____________________ CMA # ____________________ X-Ray #___________________ Desired Wage $___________ an hour CPR # ____________________ MT #______________________ Minimum Wage you will accept $___________ an hour OTHER____________________Will you work in a smoke free office? Yes No Date able to start work: ________________
Benefits Required: None Medical Dental Vacation Retirement Education Other: __________________________________________________________________________________ EMPLOYMENT HISTORY: (Start with last or current employer) Start Date ________ Last or Present Employer ________________________________________________ End Date ________ City/State __________________________________ Phone ___________________ Title __________________________ Wage _________________ Ending Wage ____________________ Supervisor: __________________________________ May we contact this employer? Yes No Were you terminated? Yes No Reason for Leaving: __________________________________
Start Date ________ Previous Employer _____________________________________________________ End Date ________ City/State __________________________________ Phone ___________________ Title __________________________ Wage _________________ Ending Wage ____________________ Supervisor: __________________________________ May we contact this employer? Yes No Were you terminated? Yes No Reason for Leaving: __________________________________
Start Date ________ Previous Employer _____________________________________________________ End Date ________ City/State __________________________________ Phone ___________________ Title __________________________ Wage _________________ Ending Wage ____________________ Supervisor: __________________________________ May we contact this employer? Yes No Were you terminated? Yes No Reason for Leaving: __________________________________
Volunteer Experience: ____________________________________________________________________
Have you ever been convicted of a felony? Yes No If Yes provide details: ______________________ _______________________________________________________________________________________
Circle locations you are willing to work:
Salem Stayton Silverton Woodburn McMinnville Albany West Salem Scio Mt. Angel Mollala Newberg Corvallis Keizer Aumsville Monmouth Dallas Independence Grand Ronde
REFERENCES: (Professional References Preferred) Name: ________________________________ Title ______________________ Phone ______________ Name: ________________________________ Title ______________________ Phone ______________ Name: ________________________________ Title ______________________ Phone ______________
I understand that misrepresentation or omission of facts called for in this application or the presentation of false or misleading documents, certificates, or licenses will be sufficient cause for cancellation of consideration for employment or dismissal from employment. I hereby give my consent for employee(s) of CanStaff Employment Services to obtain a criminal back ground check (State and/or Federal) and to contact my references for the purpose of verifying my work history and obtaining statements from past/present employers, co-workers, and/or subordinates that pertains to my work habits, attitudes, and reliability (except actions that will adversely affect my present employment). I further consent to the release of the information obtained to potential employers. I release CanStaff Employment Services and its employees from all liability as it relates to the above actions.
I, the undersigned applicant, authorize CanStaff Employment Services to represent me to their clients for employer paid positions only. I understand I am under no financial responsibility to the service, nor will there by any financial responsibility on my part to the employer.
_____________________________________ ________________________________________ Applicant’s Signature Date CanStaff Employment Services Date |