Contact Us  •  Home Page
Elite Staffing Services Inc.
Employment Application Employment Application
Social Security #:
Applicant Name:
Phone:
Alternate Phone:
Number Belongs To:
Address:
City:
State:
Zip:
Classification:
RN LPN CNA HHA
Clerical Medical  
Medical Certificate or License Number:
State:
Expiration Date: / /
Transportation Method:
Car Bus Ride Walk
How far are you willing to travel?
Preferred Employment: (Check all that Apply)
1st Shift 2nd Shift 3rd Shift
Days Weekends  
Full-Time Part-Time  
Type of Work Experience: (Check all that Apply)
Home Health CCU Charge Nurse
Tele/NICU Clerical Pediatric
Medicare Subacute Nursing Home
ER Assisted Living Privacy Duty
ICU Industrial  
Other:
How did you hear about us?
Yellow Pages Newspaper
Other:
Are you currently employed?
Yes No
if No, last date worked:
Have you ever worked for another temporary agency?
Yes No
If Yes, which one(s):
Education:
Years of High School Years of College Degree
Check any of the following that apply to you:
Bilingual Valid Drivers License ACLS
CPR First Aid I-V Certified
List any other certificates or licenses:
Have you ever been convicted of an offense other than a minor traffic violation?
Yes No
If Yes, please explain:
Employment History
#1
Company Name:
Phone:
Supervisor:
Address:
City:
State:
Zip:
Start Date: / / End Date: / /
Job Duties:
Starting Salary: End Salary:
Reason for Leaving:
#2
Company Name:
Phone:
Supervisor:
Address:
City:
State:
Zip:
Start Date: / / End Date: / /
Job Duties:
Starting Salary: End Salary:
Reason for Leaving:
#3
Company Name:
Phone:
Supervisor:
Address:
City:
State:
Zip:
Start Date: / / End Date: / /
Job Duties:
Starting Salary: End Salary:
Reason for Leaving:
#4
Company Name:
Phone:
Supervisor:
Address:
City:
State:
Zip:
Start Date: / / End Date: / /
Job Duties:
Starting Salary: End Salary:
Reason for Leaving:
Reference:
Phone:
Relationship:
Emergency Contact:
Phone:
Relationship:
Address:
City:
State:
Zip:
I agree that I will settle any and all previously unasserted claims, disputes or controversies arising out of or relating to my application or candidacy for employment and/or cessation of employment with Elite Staffing Services, exclusively by final and binding arbitration before a neutral Arbitrator. By way of example only such claims include claims under federal state and local statutory or common law, such as the Age Discrimination in Employment Act, Title VII of the Civil Rights Act of 1964, as amended, including the amendments of the Civil Rights Act of 1991, the Americans with Disabilities Act, the law of contract and the law of tort.�

Based upon the U.S. Supreme Court’s decision in (Circuit City Stores, Inc. v. Adams, No. 99-1379).

I Agree to these terms

Please Read Carefully
I do further authorize Elite Staffing Services to investigate, request and receive any information it deems appropriate, in its sole discretion, relating to my past employment, education or activities. I indemnify Elite Staffing Services against any liability which may result from such investigation and receipt of information. Any false answer or statement or implication by me to Elite Staffing Services or any of its clients shall be sufficient cause for denial or discharge from any temporary employment which I may secure. If I am temporarily employed by Elite Staffing Services, I agree to strictly obey the work rules and regulations of Elite Staffing Services and any of its clients as well as any changes in work rules and regulations as they may occur from time to time. I understand that nothing contained in the application or in the granting of an interview or in any policy practice is intended to create an employment contract between Elite Staffing Services and myself. No promise regarding employment have been made to me and I understand that no such promise or guarantee is binding upon Elite Staffing Services. If a temporary employment relationship is established, I understand that such relationship can be terminated at any time by Elite Staffing Services for any reason.

I Agree to these terms

Applicant Comments/Suggestions: