Online Application

Name:	(Last, First M.I.)
Current Address
Street:
City:	,   State:     Zipcode:
Permanent Address   (check here if same as above )
Street:
City:	,   State:     Zipcode:
Social Security #:	(with or without dashes)
Home Phone:	(include area code)
Work Phone:	(include area code)
Cellular Phone:	(include area code)
Pager Number:	(include area code)
Email:
Website:	(if applicable)

Professional Certifications:

(Please include state of issue, certification #, and expiration date)

Professional License(s):

(Please include year of issue, state of issue, license #, and expiration date)

Current Area(s) of Specialty:

(Please describe area of specialty, years of experience, and training)

Equipment Experience:

(Please describe your equipment experience)

Chicken Pox Statement:

Yes, I have had chicken pox       No, I have not had chicken pox

Professional Liability Statement:

Yes, I currently hold liability insurance       No, I do not currently hold liability insurance

Areas of Interest City/State Preference

(Please enter cities/states preferred)

Specialty Area Preference

(Please enter specialty preferred)

Facility Preference

(Please enter facility type preferred)

Applicant's Certification And Agreement (Please Read Each Statement Carefully Before Submitting) I CERTIFY that all information provided in this employment application is true and complete. I understand that any false information may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date. If Fast Trak Temps, Inc. employs me; I will follow all company rules and guidelines. I UNDERSTAND that the employer may request an investigative consumer report from a consumer-reporting agency. This report may include information as to my character, reputation, personal characteristics and mode of living obtained from interviews with neighbors, friends, former employers, schools and others. I understand I have a right to make a written request within a reasonable time for the disclosure o the name and address of the consumer reporting agency so that I may obtain a complete disclosure of the nature and scope of the investigation. I AUTHORIZE the investigation of any or all statements contained in this application and also authorize any person, school, current employer (except as previously noted), past employers and organizations from any legal liability in making such statements. I UNDERSTAND that if I am extended an offer of employment it may be conditioned upon my successfully passing a complete pre-employment physical examination. I consent to the release of any or all-medical information as may be deemed necessary to judge my capability to do the work for which I am applying. I UNDERSTAND I may be required to successfully pass a drug screening examination. I hereby consent to a pre and/or post employment drug screen as a condition of employment, if required. I UNDERSTAND that this application or subsequent employment does not create a contract of employment nor guarantee employment of any definite period of time. If employed, I understand that I have been hired at the will of the employer and I may voluntarily leave my employment or Fast Trak Temps, Inc. may terminated my employment at any time, with or without cause and with or without notice. I acknowledge that no written or oral statements have been made to or relied upon by me regarding the length of my employment with Fast Trak Temps, Inc. or the reasons for which my employment can be terminated.       *note - by submitting this form, you are agreeing to the above Information supplied in this Employment Application is strictly confidential.