Job Online Application Form

ANS Staffing Agency Job Application for RN/LPN/CNA
YES! I am interested in an employment opportunity. Please respond fully to each question in this application. Answering only the questions asked as providing other extraneous information in this career center may void your application. I understand that I may attach a resume to this form after completing the information requested below. I understand that completing only this interest form and clicking “Continue” will allow me to be considered for employment. I also understand that I am strongly encouraged to complete the remainder of the application after advancing to the next screen. However, if I choose not to complete the full application at this time, I understand I will be required to do so if scheduled for an interview.
If you would like to inquire about the status of your application or have specific questions about the position itself, please contact ANS HR manager at 347- 000-0000

Come work with us

Contact Information

First name

Middle Name

Last name

Have you worked under other names (alias, maiden, nickname) in the last five (5) years?

Yes

Street Address (No P.O. Boxes)

Apartment/Unit #

Zip Code

City

State

Preferred Phone Number

Alternate Phone Number

Email Address

I'd like to receive communications via text message.

Yes

Schedule

Date Available to Start:

Work Preferences (check all that you are interested in):

What shift schedule(s) are you looking for?

Please indicate what days you are available to work:

License and Certification

Do you have a current license or certification? (All licensed and/or certified positions require proof of current license or certification.)

Have you ever been sanctioned, disciplined, and/or excluded by a duly authorized regulatory agency, or are there any current restrictions or limits on your job-related license(s) or certifications(s)?

Are there currently any pending actions or active investigations related to a job-related license or certification that you currently hold or held in the past?

Additional Information

Are you eligible to work in the U.S.?

Are you at least 18 years old?

How did you learn of this position?

Have you ever applied with or been employed by ANS Staffing Agency?

Are you currently excluded, debarred, suspended, or otherwise ineligible to participate in any Federal health care program such as Medicare, Medicaid or TriCare?

Are you willing to relocate for this position or other opportunities at ANS Staffing Agency?

Will you submit to a drug test, background check, and physical examination (if permitted by State law) after you have received a conditional offer of employment?

Can you perform the essential functions of the job with or without a reasonable accommodation? (Note: If you have any questions about the essential functions of this job, please contact ANS Staffing Agency

Can you travel if the job requires it?

Do you know anyone who works for ANS Staffing Agency?

Please provide a brief summary of work-related skills, qualifications, and/or relevant experience related to this position.

Resume and Cover Letter

How many years of relevant job experience do you have?

EEO Information (Voluntary)

Gender

Race

Agreements

I hereby certify that the information in this form (and any accompanying documents and/or any additional information requested as part of the application) is true and complete to the best of my knowledge. I understand that any misrepresentation or failure to disclose information on this form may result in my disqualification from further consideration for employment or, if employed, my termination.

I understand that the satisfactory completion of a background check and drug screen (conducted after an offer of employment) is a condition of employment with Life Care Centers of America, Inc.

DO NOT CONTINUE UNTIL YOU HAVE READ THE STATEMENT ABOVE. By continuing to the next screen, I certify that I have read, fully understand, and accept all terms of the foregoing statement. I consent to conducting this transaction electronically, and I agree that my eSignature has the same force and effect as my handwritten signature on this document.

Signature