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Personal Information

First Name*

Last Name*



Zip Code*

Your Email*

Primary Phone*

Secondary Phone

Optional: Upload your Resume

Additional Information

Do you have a valid driver's license?*

Are you a veteran?*

Have you ever been convicted
of a Misdemeanor or Felony?*

Rate of pay desired:

Availability Information

Days you are available to work*:

Times available to work*:


Highest Education Level*:
High SchoolEquivalentPost High School


Previous Employment

Company Name:

Company's Phone:

Dates Worked:

Salary or Hourly Wage:

Job Title:


Reason for Leaving:

May we contact this employer for a reference check?

Professional References

Please list at least 2 references

Name of Reference:

Company Name:

Phone Number:

Fax Number:

Name of Reference:

Company Name:

Phone Number:

Fax Number:

Name of Reference:

Company Name:

Phone Number:

Fax Number:

Release of Information

  allow my perspective employer ASAP MedStaff, to verify information given to him or her on my application for employment and do hereby releases ASAP Staffing, State Police, and their assigns or successors from any liability of claims and authorize the State Police to release to ASAP Staffing my conviction criminal history information.

Your Driver's License Number*

Issuing State*

Date of Birth*



ASAP MedStaff agrees to use the information from the Department of State Police to verify information of your employment application, the statements you have made in regards to your employment, and for any determination into your good moral character.


I am aware that federal law provides for imprisonment and/or fines for false statements of use of false documents in connection with the completion of this form.

I attest, under penalty of perjury, that I am (check one of the following)*:
A citizen of the United StatesA noncitizen national of the United StatesA lawful permanent residentAn alien authorized to work

Alien Registration Number (if applicable)

Sign and Submit

I confirm that the facts set forth in my application and submitted resume are true and complete to the best of my knowledge, that I shall ensure that such facts remain true and accurate for the duration of my employment with ASAP Staffing.

Electronic Signature:*