Careers Form

* = Required Information

EMPLOYMENT APPLICATION

Best Choice Agency Inc is an equal employment opportunity employer. Please be advised we consider applicants for all positions without regard to race, color, religion/creed, sex/gender, age, national origin, disability/handicap, marital or veteran status, sexual orientation, or any other legally protected status. Inc to Best choice agency.

PERSONAL INFORMATION

Last Name *

First Name *

Middle Initial *

Street Address*

City*

State*

Zip*

Home Phone

Cell phone*

Birthdate*

Email*

Are you eligible to work in the US?*

Yes

Do you require sponsorship to work in the US?*

Yes

Social Security Number*

Are you over the age of 18?*

Yes

Emergency Contact*

Phone*

Position(s) Applying For*

Nurse or CNA License Number*

Are there any specific hours or days that you are not available for work? If so, please list below: *

EDUCATION

High School

Name of school*

Address*

Number of years completed?*

Major/degree*

College

Name of school

Address

Number of years completed?

Major/degree

Trade School

Name of school

Address

Number of years completed?

Major/degree

Graduate School

Name of school

Address

Number of years completed?

Major/degree

Do you have a current license to work in Massachusetts?*

Yes

Has your nursing license ever been suspended or revoked?*

Yes

Explain

Have you ever been disciplined for being unprofessional or unethical (i.e: abuse or neglect?)*

Yes

Explain

HAVE YOU EVER BEEN CONVICTED OF ANY CRIME (CIVIL OR FELONY)?*

Yes

Explain the number of convictions, the nature of the offense(s) leading to the conviction(s), how recently was/were the offense(s) committed, sentence(s) imposed, and type(s) of rehabilitation.

EMPLOYMENT HISTORY
Please list your work experience starting with your most recent or current employer and one previous employer.

Current or recent Employer name address*

Name of last supervisor and phone number*

Employment dates*

Pay rate*

Job Title*

Reason for leaving*

Job Description*

Current or recent Employer name address

Name of last supervisor and phone number

Employment dates

Pay rate

Job Title

Reason for leaving

Job Description

Current or recent Employer name address

Name of last supervisor and phone number

Employment dates

Pay rate

Job Title

Reason for leaving

Job Description

Please list any additional skills, qualifications, certifications, or training that you feel is relevant to this position (e.g., speak a foreign language, CPR, or other training or special education).

REFERENCES
Please list any two professional references

Name*

Position/Title*

Address*

Phone*

Name

Position/Title

Address

Phone

Name

Position/Title

Address

Phone

PLEASE READ CAREFULLY

In exchange for the consideration of my job application by BEST CHOICE AGENCY INC, I agree that: BEST CHOICE AGENCY INC may terminate my employment at any time with or without cause. I authorize the investigation of all statements contained in this application. I understand that any misrepresentation or omission of facts will lead to automatic dismissal at any time without notice. I hereby authorize BEST CHOICE AGENCY INC to perform a criminal background check as required by state law.

Signature of Applicant*

Date*