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Application form

Full Name
Birthday
Address
Phone
Email
Position
Are you legally eligible to work in the USA
Are you under 18 years old?
Have you ever been convicted of a crime?
When can you start working?
Specify Days You Are Availble
Specify times you are available

Are there any limitations that HealGen Staffing Partners should be aware of that could prevent you from performing the essential functions of the position you are applying for?
Education

Diploma, Degree, or Certificate Received
Have you received a Certified Nursing Assistant Certificate?
State Professional Certificate was Issued in
Date Issued
Certificate Number
Have you received a Nursing License?
State Professional License was Issued in
Date Issued
License Number
Have you ever had a technical or professional license application denied or a technical or professional license put on probationary status or suspended or revoked?
If you answered yes, please explain
Have you ever been convicted of or pled guilty to a crime other than a minor traffic violation within 5 years?
If you answered “ yes”, please explain, stating the nature of the crime, the name of the court and the date of the conviction or plea:
Previous Employer Name, and Number
What was your title?
Date employment began
Date employment ended
Previous Employer Name, and Number
What was your title?
Date employment began
Date employment ended
Previous Employer Name, and Number
What was your title?
Date employment began
Date employment ended
Have you ever walked off a job?
If You Answered “Yes” To The Question Above, Please Explain
How did you hear about us? / Who referred you to us?

Voluntary Self-Identification of Disability

Why are you being asked to complete this form?

The law requires us to provide equal employment opportunities to qualified people with disabilities. To do this, we must ask applicants and employees if they have a disability or have ever had one. People can become disabled, so we need to ask this question at least every five years. Completing this form is voluntary, and we hope that you will choose to do so. Your answer is confidential.

How do you know if you have a disability?

A disability is a condition that substantially limits one or more of your “major life activities.” If you have or have ever had such a condition, you are a person with a disability. Disabilities include, but are not limited to:
 

  • Alcohol or other substance use disorder (not currently using drugs illegally)
  • Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, HIV/AIDS
  • Blind or low vision
  • Cancer (past or present)
  • Cardiovascular or heart disease
  • Celiac disease
  • Cerebral palsy
  • Deaf or serious difficulty hearing
  • Diabetes
  • Disfigurement, for example, disfigurement caused by burns, wounds, accidents, or congenital disorders
  • Epilepsy or other seizure disorder
  • Gastrointestinal disorders, for example, Crohn's Disease, irritable bowel syndrome
  • Intellectual or developmental disability
  • Mental health conditions, for example, depression, bipolar disorder, anxiety disorder, schizophrenia, PTSD
  • Missing limbs or partially missing limbs
  • Mobility impairment, benefiting from the use of a wheelchair, scooter, walker, leg brace(s) and/or other supports
  • Nervous system condition, for example, migraine headaches, Parkinson’s disease, multiple sclerosis (MS)
  • Neurodivergence, for example, attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder, dyslexia, dyspraxia, other learning disabilities
  • Partial or complete paralysis (any cause)
  • Pulmonary or respiratory conditions, for example, tuberculosis, asthma, emphysema
  • Short stature (dwarfism)
  • Traumatic brain injury

Disability Status*
Veteran Status: If you believe you belong to any of the categories of protected veterans, please indicate by making the appropriate selection.*

Voluntary Self-Identification


For government reporting purposes, we ask candidates to respond to the below self-identification survey. Completion of the form is entirely voluntary. Whatever your decision, it will not be considered in the hiring process or thereafter. Any information that you do provide will be recorded and maintained in a confidential file.


Race and ethnicity
Gender
STATEMENT OF EQUAL OPPORTUNITY, CORPORATE POLICY AND EMPLOYMENT GUIDELINES.......I understand that any false statements or material omissions made as a part of the application will disqualify me from further consideration for employment, and if discovered later will be grounds for discharge. I also understand that any offer of employment is contingent upon the result of a pre- employment medical examination, drug screen, criminal background check, and reference check. I authorize my former employers to release all information concerning my employment, and I further authorize the release of any such information during or after my employment without prior notification. I consent to any and all medical examinations and drug screening and background checks by Healgen Staffing Partners LLC. I understand that all results of such examinations / screens/ checks are the property of Healgen Staffing Partners LLC and they remain confidential. I understand that if I am an employee of Healgen Staffing Partners LLC, then my employment is “at will” and may be terminated by me or by Healgen Staffing Partners LLC at any time with or without cause, for any reason.*
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