Thank you for your interest in joining S&S Healthcare Staffing. We are always looking for dedicated and compassionate healthcare professionals to provide excellent care to our clients. Please complete the following application form to be considered for employment with our agency.

    Applicant Information
    First Name
    Last Name
    Email
    Street Address
    City
    State
    Zip
    Referred to us by
    Telephone
    Cellphone
    Date of Birth
    Date Available

    Position(s) applied for Certified Nursing Assistant (CNA)Licensed Practical Nurse (LPN)Registered Nurse (RN)Other
    Availability Full TimePart-TimePer Diem/On-Call
    Available Shift Times Day ShiftEvening ShiftNight ShiftWeekends
    Rate of Pay Expected per hour
    How did you hear about us?
    Resume

    Please briefly outline the reason you are applying for employment at this company?

    YesNo
    - If currently employed, may we contact your employer?

    YesNo
    - Are you legally eligible for employment in this country?

    YesNo
    - Are you available to work overtime if required?

    YesNo
    - Have you applied with this company before?

    YesNo
    - Have you been employed at this company before?

    YesNo
    - Do you have any friends or family employed at this location?

    YesNo
    - If considered for hiring, will you agree to provide a criminal background check?

    YesNo
    - Have you been convicted of a crime?
    Please explain
    Educational Background
    List the previous three (3) educational institutions attended, beginning with the most recent.
    School #1
    City/State/Province
    Degree(s) / Diploma(s) Earned
    Graduated? YesNo

    School #2
    City/State/Province
    Degree(s) / Diploma(s) Earned
    Graduated? YesNo

    School #3
    City/State/Province
    Degree(s) / Diploma(s) Earned
    Graduated? YesNo
    Nursing Background What state Nursing License do you possess?
    Type
    Issue Date
    Expiration Date
    License Number
    Valid States

    Type
    Issue Date
    Expiration Date
    License Number
    Valid States

    Do you have the following?
    BLS YesNo
    Issue Date:
    Expiration Date:

    ACLS YesNo
    Issue Date:
    Expiration Date:
    Employment Background
    Employer #1
    Telephone
    Address
    Job Title
    Employment Start Date
    Employment End Date
    Immediate Supervisor
    Supervisor Title
    Supervisor Phone #
    Reason for Leaving
    May we contact for reference? YesNo

    Summarize the type of work
    Employer #2
    Telephone
    Address
    Job Title
    Employment Start Date
    Employment End Date
    Immediate Supervisor
    Supervisor Title
    Supervisor Phone #
    Reason for Leaving
    May we contact for reference? YesNo

    Summarize the type of work
    Employer #3
    Telephone
    Address
    Job Title
    Employment Start Date
    Employment End Date
    Immediate Supervisor
    Supervisor Title
    Supervisor Phone #
    Reason for Leaving
    May we contact for reference? YesNo

    Summarize the type of work
    Employer #4
    Telephone
    Address
    Job Title
    Employment Start Date
    Employment End Date
    Immediate Supervisor
    Supervisor Title
    Supervisor Phone #
    Reason for Leaving
    May we contact for reference? YesNo

    Summarize the type of work

    References List the name, relationship, number of years acquainted, and phone number of three references. (No relatives please).
    Name
    Relationship
    Years Acquainted
    Phone Number
    Name
    Relationship
    Years Acquainted
    Phone Number
    Name
    Relationship
    Years Acquainted
    Phone Number
    I certify that all the information I have provided is true, complete and correct.
    • The information contained within this application or any cover letter or resume attached is not shared with any third parties. The information is used by the employer only as an aid in the hiring decision making process. The applicant, by signing the application gives the employer consent to collect the information contained herein and use for the purpose specified.
    • I authorize this company to investigate all statements contained on this application. I understand that any misrepresentation or omission of facts called for is cause for immediate disqualification and/or if employed, immediate dismissal.
    • I understand that if I am hired, I will be required to provide criminal background check at my cost, proof of identity and legal authority to work in Canada, proof of certifications or educational qualifications, and a drivers abstract (if applicable).
    • Furthermore, I understand and agree that if employed, I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same rights to terminate my employment at any time, with or without prior notice, except as may be required by law. This application does not in any way constitute an agreement or contract for employment.
    Applicant's Signature
    Scroll to Top