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pharmacy job, physical therapist job, radiology job

Protouch Staffing. Inc.
Application for Employment
Thank you for your interest in locating employment opportunities through Protouch Staffing, Inc. We will review your credentials and contact those individuals who are most qualified for our current vacancies.
* required information

   RECRUITERS NAME AND EMAIL
Recruiter Name: *
Recruiter Email Address:  *
 
   EMAIL AND LOGIN PASSWORD
   

You may use the email and password combination that you enter below to apply for other positions. Both the email and password fields must be completed to use this feature.
E-Mail Address: *
Password:  *
 
  PERSONAL INFORMATION
   
First Name: *     MI:
Last Name: *
Address: *
City: *
State: *
Zip: *
   
Social Security Number: *
 (999-99-9999)
Home/Other Phone: *
Work Phone: 
Fax: 
Mobile Phone: 
Pager: 
   
List other names under which your records may be found if this does not apply please enter NA: *
   
Best way to contact:
Best time to contact:
   
   
  EDUCATION
  Name and
Location of School
 Course of Study / Major Did you graduate?    No. of Years Completed  List Diploma or Degree
Grade/High School/GED Yes
College/University Yes
Graduate/Professional Yes
Trade/Vocational/Other Yes

If currently enrolled in school, list hours and days attending.



  SKILLS / EXPERIENCE
 
 
Typing Speed - WPM:  Errors:
Software Packages:
Office Equipment:
Other skills not mentioned above:
   
 
  LICENSES

Professional Licensure
License/Certification State/License No. Date/Year Issued Expiration Date Temporary Permanent
   
   
   


License(s) pending in (state/country):


Has a state licensing authority ever revoked, suspended or placed conditions upon your professional license(s)?     Yes No
  If yes, please explain circumstances and outcome.
 

  WORK HISTORY

List all previous employment starting with your most recent position. Account for any time during this period that you were unemployed by stating the nature of your activities in the box provided. Please indicate if you were employed under a different name.
Are you currently employed? Yes No

 1. Most recent employer
Name of Company:
Street Address:
City, State, Zip:
Employer's Phone:
Other Name(s) Used:
Job Title:
From (mo/yr):
To (mo/yr):
Salary:
Supervisor's Name:
Employment Status: full-time part-time on call 		Job Duties and Responsibilities:

Reason for Leaving:


May we contact this employer for a reference ?
Yes No
 2.
Name of Company:
Street Address:
City, State, Zip:
Employer's Phone:
Other Name(s) Used:
Job Title:
From (mo/yr):
To (mo/yr):
Salary:
Supervisor's Name:
Employment Status: full-time part-time on call 		Job Duties and Responsibilities:

Reason for Leaving:


May we contact this employer for a reference ?
Yes No
 3.
Name of Company:
Street Address:
City, State, Zip:
Employer's Phone:
Other Name(s) Used:
Job Title:
From (mo/yr):
To (mo/yr):
Salary:
Supervisor's Name:
Employment Status: full-time part-time on call 		Job Duties and Responsibilities:

Reason for Leaving:


May we contact this employer for a reference ?
Yes No
 4.
Name of Company:
Street Address:
City, State, Zip:
Employer's Phone:
Other Name(s) Used:
Job Title:
From (mo/yr):
To (mo/yr):
Salary:
Supervisor's Name:
Employment Status: full-time part-time on call 		Job Duties and Responsibilities:

Reason for Leaving:


May we contact this employer for a reference ?
Yes No
 
State the nature of your activities during
any period of time not worked: 		  
Have you ever been discharged
from a job, or asked to resign? 		   Yes  No
   If yes, please explain.
  
 
  MILITARY SERVICE

 

Were / Are you a member of the U.S. Armed Forces? Yes No
   
Branch of Service:
Area(s) of Specialty:
Service or Serial Number:
 
  ADDITIONAL INFORMATION
 
What is your minimum salary requirement?
Which job status/shift would you accept?
(please check all that apply)
Shift
day
evening
night
weekend

Please answer all of the following questions.
* Yes No Have you ever been convicted of a crime or received a verdict other than not guilty?
If yes, describe when the conviction occurred, location, facts and circumstances, and any facts pertaining to rehabilitation. (Do not list any criminal charges for which records have been expunged. A criminal offense will not necessarily bar employment.)

* Yes No Have you ever been excluded from participating, as a Service Provider or Contractor, in the Medicare or Medicaid program?
* Yes No The Immigration Reform and Control Act of 1986 states, offers of employment are conditioned upon satisfactory proof of identity and legal ability to work in the United States. If hired, can you furnish proof that you are legally permitted to work in the United States?
 
  RESUME

Resume
To cut and paste your resume:
1. Highlight the text on the resume you want to copy.
2. Press 'Ctrl C' to copy (Hold down the Ctrl key and press C).
3. Place the cursor in the RESUME box below.
4. Press 'Ctrl V' to paste the information.

Cover Letter

Resume

 

  APPLICATION FOR EMPLOYMENT RELEASE OF INFORMATION

Important
Please read carefully before signing. If you do not understand any of the following please ask for assistance.

  • I have truthfully disclosed all information requested in this application.
  • I authorize contact with any person or entity named in this application and any other person or entity who may have knowledge concerning my past; and I authorize all those who are acquainted with me previous employers, schools, universities, licensing agencies, state boards, physicians, professionals, institutions, references, law enforcement agencies asked to provide a record of criminal history in accordance with applicable State Law, and others - to furnish any and all information they may have concerning me which may be material to my qualifications for the job for which I have applied.
  • I agree to indemnify and hold harmless the person to whom this request is presented, and his agents and employees, from and against all claims, damages, losses, and expenses, including reasonable attorneys fees, arising out of or by reason of complying with this request.
  • I understand that I may be allowed to begin work prior to completion of my background check and employment verification. I further understand that my employment may be terminated upon unfavorable completion of my background cheek and employment verification.
  • As a condition of employment, I hereby consent to any drug/alcohol testing procedure required by potential employers, or any other means for assuring that the workplace is free of drugs, controlled substances, and alcohol. Any applicant whose screen shows positive results or who has been shown to have tampered with the sample will have his/her application for employment rejected and withdrawn from further consideration.
  • I understand that I may be allowed to begin work prior to submitting to the required drug screen. I further understand that if such drug screen is positive that my employment with a client of Protouch Staffing, Inc. will be terminated immediately.
  • I understand that an offer of employment may be conditioned upon the results of a pre-employment medical examination, and that any referral to a private doctor for suggested follow-up will be at my own expense. I understand that in the event I obtain employment, my employment is not for any definite term, and may be terminated by the employer or by me at any time, for any reason, with or without notice. I understand that there is no promise that employment will continue for a set period of time, nor is there any promise that my employment will be terminated only under particular circumstances. I agree to abide by all present and subsequently issued rules and policies of the employer.

Candidate's/Applicant's Signature:
Date: 

 

   
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