Employment Form

It is our policy to provide equal employment opportunity to all qualified persons without regard to race, creed, color, religious belief, sex, age, national origin, ancestry, physical or mental handicap or veteran status.

Personal Information

FULL NAME

ADDRESS

CITY

STATE

ZIP CODE

PHONE NUMBER

DATE OF BIRTH

GENDER

EMAIL

Position Information

POSITION APPLYING FOR

ARE YOU A U.S. CITIZEN?

IF NO, DO YOU HAVE WORK AUTHORIZATION?

ARE YOU AT LEAST 18 YEARS OLD?

HAVE YOU EVER WORKED FOR ALLSTAR HEALTH SERVICES?

DO YOU HAVE A VALID MD LICENSE?

SHIFTS AVAILABLE

MorningsAfternoonsEvenings24hrs/Live-ins

WHEN CAN YOU START?

Preferred Location

SPECIFY CITIES WITHIN SELECTED COUNTIES (WRITE "ALL" IF ANY)

Education

HIGH SCHOOL NAME

GRADUATED HIGH SCHOOL?

HIGH SCHOOL DEGREE & YEAR

COLLEGE/UNIVERSITY NAME

GRADUATED COLLEGE?

COLLEGE DEGREE & YEAR

OTHER EDUCATION

GRADUATED?

OTHER EDUCATION DEGREE & YEAR

Employment History (Most Recent First)

Most Recent Employer

COMPANY NAME

ADDRESS

NATURE OF BUSINESS

TELEPHONE

START DATE

END DATE

STARTING WAGE

STARTING POSITION

ENDING POSITION

SUPERVISOR NAME

MAY WE CONTACT?

IF NO, EXPLAIN WHY

RESPONSIBILITIES

REASON FOR LEAVING

CPR Experience

CPR EXPERIENCE - ADULTS

CPR EXPERIENCE - CHILDREN

CPR EXPERIENCE - INFANTS

Criminal History

HAVE YOU BEEN CONVICTED OF A CRIME OTHER THAN MINOR TRAFFIC OFFENSE IN THE LAST 10 YEARS?

IF YES, PLEASE EXPLAIN

Skills and Qualifications

SUMMARIZE YOUR SKILLS AND QUALIFICATIONS

Language Skills

LANGUAGE 1

FLUENCY LEVEL

Speak someSpeak fluentlyReadWrite

LANGUAGE 2

FLUENCY LEVEL

Speak someSpeak fluentlyReadWrite

ADDITIONAL LANGUAGES

How Did You Hear About Us?

SELECT ALL THAT APPLY

Employee ReferralWalk-inSocial MediaInternet/Search Engine

IF EMPLOYEE REFERRAL, SPECIFY NAME

Declaration and Authorization

I certify that my responses are true and complete to the best of my knowledge. I understand that false or misleading information in my application may result in termination of employment.I authorize Allstar Health Services, Inc. to make inquiries into my employment, educational, financial, medical history and other related matters as necessary for an employment decision.I understand that this application does not constitute an employment agreement.

Personal Information

FULL NAME

ADDRESS

CITY

STATE

ZIP CODE

PHONE NUMBER

DATE OF BIRTH

GENDER

EMAIL

Position Information

POSITION APPLYING FOR

ARE YOU A U.S. CITIZEN?

IF NO, DO YOU HAVE WORK AUTHORIZATION?

ARE YOU AT LEAST 18 YEARS OLD?

HAVE YOU EVER WORKED FOR ALLSTAR HEALTH SERVICES?

DO YOU HAVE A VALID MD LICENSE?

DAYS AVAILABLE

SHIFTS AVAILABLE

WHEN CAN YOU START?

Preferred Location

SELECT PREFERRED COUNTIES

SPECIFY CITIES WITHIN SELECTED COUNTIES (WRITE "ALL" IF ANY)

Education

HIGH SCHOOL NAME

GRADUATED HIGH SCHOOL?

HIGH SCHOOL DEGREE & YEAR

COLLEGE/UNIVERSITY NAME

GRADUATED COLLEGE?

COLLEGE DEGREE & YEAR

OTHER EDUCATION

GRADUATED?

OTHER EDUCATION DEGREE & YEAR

Employment History (Most Recent First)

Most Recent Employer

COMPANY NAME

ADDRESS

NATURE OF BUSINESS

TELEPHONE

START DATE

END DATE

STARTING WAGE

STARTING POSITION

ENDING POSITION

SUPERVISOR NAME

MAY WE CONTACT?

IF NO, EXPLAIN WHY

RESPONSIBILITIES

REASON FOR LEAVING

CPR Experience

CPR EXPERIENCE - ADULTS

CPR EXPERIENCE - CHILDREN

CPR EXPERIENCE - INFANTS

Criminal History

HAVE YOU BEEN CONVICTED OF A CRIME OTHER THAN MINOR TRAFFIC OFFENSE IN THE LAST 10 YEARS?

IF YES, PLEASE EXPLAIN

Skills and Qualifications

SUMMARIZE YOUR SKILLS AND QUALIFICATIONS

Language Skills

LANGUAGE 1

FLUENCY LEVEL

LANGUAGE 2

FLUENCY LEVEL

ADDITIONAL LANGUAGES

How Did You Hear About Us?

SELECT ALL THAT APPLY

IF EMPLOYEE REFERRAL, SPECIFY NAME

Declaration and Authorization