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ONLINE APPLICATION Download Microsoft Word Document Submit your application to have KMS contact you today. Personal Information required fields Last Name First Name Social Security No. - - Address City State - select - AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA ME MD MI MO MN MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip Are you 18 years or older? yes no Phone Desired Employment required fields Position Date You Can Start Salary Desired Are you employed now? yes no If so, may we inquire of your present employer? yes no     Ever applied to this company before? yes no Where? When?     Ever worked for this company before? yes no Where? When?     Reason for leaving Name of last supervisor at this company Who referred you to this company? - select - Employment Agency Newspaper Ad Friend Walk-in State employment office College placement Service Other Education no required fields in this section School level Name and Location of school No. of years attended Did you graduate? Subjects studied Grammar school yes no High school yes no College yes no Trade, Business or Correspondence School yes no General no required fields in this section Subjects of Special Study or Research work Special training Special Skills List Below Last three Employers, starting With The Most Recent Note:ONLY 1 EMPLOYER REQUIRED ENTRY NOT ALL!! Former Employers [1] required fields Name of present or last employer Address City State - select - AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA ME MD MI MO MN MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip     Staring Date Leaving Date Job Title     Weekly Staring Salary Weekly Final Salary     May we contact your supervisor? yes no Name of Supervisor Title Phone Fax     Description of position Description of position Former Employers [2] no required fields in this section Name of present or last employer Address City State - select - AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA ME MD MI MO MN MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip     Staring Date Leaving Date Job Title     Weekly Staring Salary Weekly Final Salary     May we contact your supervisor? yes no Name of Supervisor Title Phone Fax     Description of position Description of position Former Employers [3] no required fields in this section Name of present or last employer Address City State - select - AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA ME MD MI MO MN MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip     Staring Date Leaving Date Job Title     Weekly Staring Salary Weekly Final Salary     May we contact your supervisor? yes no Name of Supervisor Title Phone Fax     Description of position Description of position Below, Give the Names Of Three Persons You are Not Related to, Whom You Have Known at Least One Year References no required fields in this section Name Address Business Years Acquainted 1. 2. 3. Service Record no required fields in this section Branch of Service Discharge date Rank Job duties required fields Have you been convicted of a felony within the last five years? yes no If yes, explain Additional Questions no required fields in this section Why are you interested in working for an agency? How many shifts per week do you want to work? What is your shift preference? 1st 2nd 3rd Do you have reliable transportation? yes no How far are you willing to travel for an assignment? (minutes away) 20 30 45 60 Are you barred from working at any local facilities, from previous work or agency assignments? If so, why? Are you able to be flexible in accepting assignments? Can you take assignments less than 2 hours before a shift begins? Are you currently employed? yes no If yes, what is your current work schedule? Authorization to Provide Information I, authorize Kelleron Medical Staffing to conduct a complete background investigation in order to assess my eligibility for a position requiring a high level of reliability and trustworthiness. I authorize all persons who may have information relevant to this investigation including, without limitation, prior employers, doctors, landlords, creditors and others to disclose it [including photocopies where requested] to Kelleron Medical Staffing or their agents. I hereby release and hold harmless from liability all persons on account of such disclosure. I understand that the investigation may include verification of past employment, review of personnel records maintained by any prior employer, education, and opinions of references. This authorization shall be valid for a period of time not to exceed one year following the date indicated below or until employment is terminated, whichever occurs first. The release and hold harmless contained herein shall remain in full force and effect with respect to all disclosures provided within this time period. I authorize that a photocopy of my signature below may be used to obtain information regarding the investigation. You must agree before submitting this application Date Social Security No. - -   Please make sure that all required fields are correct before submitting.

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