Jas Links Healthcare Services Inc.

                                    Jas Links Healthcare Services Inc

SUBCONTRACTOR APPLICATION

First Name _____________________________ Last Name ____________________________

Social Security Number ______-______-_________

Current Address ______________________ City _______________, State _____ Zip _______

Home Phone____________________________ Cell Phone_____________________________ Email ________________________________  Person to contact in case of emergency:

Name________________________ Relationship ______________ Phone _____-_____-______

Date available to begin employment: ________________________________

Licensure: CNA  CMA LPN  RN Other

License #_______________________________________ State_______________________________ Expiration Date____________

Certifications (include photo copies of certification held)

Professional Registrations(s)/certifications(s)

Certification_____________________________________# _______________cert. Date___________ expirations date___________

Certification_____________________________________# _______________cert. Date___________ expiration date___________

Certification_____________________________________# _______________cert. Date___________ expiration date___________

Are you a US citizen?  Yes  or   No

If you will be employed on a visa, please specify type of work visa: _______________________

Have you ever pled guilty in or been convicted of a criminal offense other than a misdemeanor?

Yes  or   No

If yes, explain: ________________________________________________________________

Has any license/certification held by you ever been subject to disciplinary action, suspension or

Revocation? Yes or  No

If yes, explain on a separate sheet: *Attach your explanation with your application___________

Applicants are considered for all positions that they are licensed to hold without regard to race, Religion, gender, national origin, age, disability, or marital or veteran status. Jas Links Healthcare Services is an equal opportunity employer.

EDUCATION

High School

Name and Address of School ____________________________________________________

Year Graduated________________ Degree or Diploma

College

Name and Address of School ____________________________________________________

Year Graduated________________ Degree or Diploma

Graduate School

Name and Address of School ____________________________________________________

Year Graduated________________ Degree or Diploma

Other School

Name and Address of School ____________________________________________________

Year Graduated________________ Degree or Diploma

Employment History

Facility: ____________________________Supervisors Name____________________________ Phone ______-_____-______City________________________________State______________

Dates of employment ___________ to ___________ Reason for leaving____________________

Position held/responsibility: ______________________________________________________

Facility: ____________________________Supervisors Name____________________________ Phone ______-_____-______City________________________________State______________

Dates of employment ___________ to ___________ Reason for leaving____________________

Position held/responsibility: ______________________________________________________

Facility: ____________________________Supervisors Name____________________________ Phone ______-_____-______City________________________________State______________

Dates of employment ___________ to ___________ Reason for leaving____________________

What Shifts are you willing to work?   1st shift    2nd shift    3rd shift     any shift

What day of the week are you available? Mon   Tues   Wed   Thurs   Fri   Sat    Sun

What distance are you willing to travel? 10 miles   20 miles   anything is fine

I certify that all of the foregoing information is a complete and accurate statement of the facts and

Understand that if any misrepresentation, omission or falsification is discovered, it will constitute grounds

For dismissal. I hereby authorize you and your agents to conduct any investigation necessary concerning

any part of my background, civil, and criminal record, education records, and any other such information

related to the position I am seeking. I release and forever hold harmless any and all parties from any

Liability in connection with the provision and use of such information. I understand that I am a

Subcontractor and responsible for any medical expenses incurred during my work hours and that

Jas Links Healthcare Services does not cover me via workman’s compensation. I understand that I will be hired as a sub-contractor and will be responsible for my own taxes. I will receive a Form 1099 at the end of each year.

I understand and agree that, if contracted out by this organization, or its clients, I will abide by the

appropriate rules and regulations, which I understand, are subject to change. I further understand that, if

hired, my employment is for definite period of time and may be terminated by either party at any time. I

further understand that as a condition of employment through Jas Links Healthcare Services Inc, I may be required to undergo a physical examination, including drug screening, to determine my ability to perform the functions of my job with reasonable consideration.

I, the undersigned, having applied for a position with Jas Links Healthcare Services Inc, do hereby authorize you to provide Jas Links Healthcare Services Inc with the information requested. I hereby authorize my former employer to furnish any or all information, personal or otherwise, which may or may not be recorded. I hereby release all such employers, including their representatives and agents, from all liabilities for any damage whatsoever for furnishing same to Jas Links Healthcare Services Inc.

Signature________________________________________________________

Name Printed_____________________________________________________

Date______________________________________

For Office Use Only

Criminal Background Complete:  ____ No Record   ____ Record    

Annual Physical ________________TB Test Results   ______ Neg. _____Positive

2 Reference Checks Complete 1)__________________2)____________________

CPR  Expiration Date: _____________________

Interview Date: ___________________ Director’s Signature:_________________

Eligible for hire_____________________ Not Eligible______________________

Pay Rate: __________________ Offer letter sent Date sent: __________________

License Verified Date: ______________