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Personal Information
First Name
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Last Name
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Middle Initial
Mailing Address
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City
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State
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Zip Code
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Phone
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Email Address
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Social Security Number
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Valid Driver's Licensed Number
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Position Applying For:
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Registered Nurse (RN)
Licensed Practical Nurse IV (LPN II)
Licensed Practical Nurse (LPN)
Certified Medication Aide (CMA)
Certified Nurse Assistant (CNA)
Scheduling Coordinator
Wage Desired (Hourly)
Type of Employment You Want (Select All that Apply)
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Full Time
Part Time
How Long do You Plan to Work Here?
Date Available to Begin
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Would you Consider Working Any Shift?
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Yes
No
Shift Preference
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1st
2nd
3rd
Weekends
Days Available
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Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Are you legally authorized to work in the United States?
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Yes
No
If you are Not a U.S. Citizen: Type of Visa you Carry
Alien Registration Number
Have you ever been convicted of a felony?
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Yes
No
If yes, please explain.
How were you Referred to AllStaff?
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AllStaff Employee
School
Social Media
Print Ad
Other
Who Were You Referred By?
Have you Previously Applied Here?
Yes
No
If yes, when?
Position
Were you previously employed here?
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Yes
No
If yes, when?
Position
Note: AllStaff Chartered has a NO-DUAL agency policy. This means that if AllStaff Chartered hires you, you would be asked not to work for any other traveling nursing agency at the same time. Would you be able to agree with this AllStaff Charted policy requirement?
This Policy Does not apply to Kansas City Metro applicants.
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Yes, I agree.
No, that doesn't work for me.
I'm applying from KC Metro Area
Signature
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