Employment Form

Please complete the form below, we shall response to you as soon as we receive your application

APPLICANT DETAILS
Full Name *
Address *
Number of Years (at this address) *
City *
State *
Zip *
Day Time Phone *
Evening Phone *
Social Security Number *
Driver License (State/Number) *
EMERGENCY CONTACT

(Who should be contacted if you are involved with any emergency)

Contact Name *
Relationship To You *
Address *
City *
State *
Zip *
Day Time Phone *
Evening Phone *
JOB POSITION APPLIED FOR
Position Applied for *
Salary Desired *
Month/Weekly/Daily *
Who referred you to our company
City
State
Zip
Day Time Phone
Evening Phone
APPLICANT EDUCATION & SKILLS
Ability or years of experience rating (1 - 5)
Typing
Microsoft Office Suite (Word, Excel etc)
Accounting/Book Keeping
Answering Telephones
Filing
Customer Service
Other Ability/Skills (if available)
Rating
Educational History
College/University Name
College/University Address
High School/GED Name
High School/GED Address
Other Training (Graduate,Technical,Vocational)
APPLICANT QUALIFICATION & AWARDS
Did You Receive A Degree? *
Degree Received (if yes)
Awards, Honors or Special Achievements
Any Military Service? *
Department (if yes)
 
APPLICANT EMPLOYMENT HISTORY
Employment Details 1:
Employer Name
Supervisor Name
Address
City
State
Zip
Job Duties
Reason for Leaving
Date of Employment (FROM)
Date of Employment (TO)
Employment Details 2:
Employer Name
Supervisor Name
Address
City
State
Zip
Job Duties
Reason for Leaving
Date of Employment (FROM)
Date of Employment (TO)
REFERENCE

Person who would be willing to provide a reference for you (i.e person not related to you)

Name *
Relationship *
Address *
City *
State *
Zip *
Day Time Phone *
Evening Phone *
ACKNOWLEGMENT
I certify that the information provided on this application is truthful and accurate. I understand that providing false or misleading information will be the basis for rejection of my application, or if employment commences immediate termination. I authorize Abah-Kross Healthcare Staffing to contact former employers and educational organizations regarding my employment and education. I authorize my former employers and educational organizations to fully and freely communicate information regarding my previous employment, attendance, and grades. I authorize those persons designated as references to fully and freely communicate information regarding my previous employment and education. If an employment relationship is created, I understand that unless I am offered a specific written contract of employment signed on behalf of the organization by its Director, the employment relationship will be "at will." In other words, the relationship will be entirely voluntary in nature, and either I or my employer will be able to terminate the employment relationship at any time and without cause. With appropriate notice, I will have the full and complete discretion to end the employment relationship when I choose and for reasons of my choice. Similarly, my employer will have the right. Moreover, no agent, representative, or employee of Abah-Kross Healthcare Staffing, except in a specific written contract of employment signed on behalf of the organization by its Director, has the power to alter or vary the voluntary nature of the employment relationship.

Abah-kross Healthcare

Contact Information

6000 Princess Garden Parkway, Lanham, MD, 20706 +301 244 0643, +301 679 7090 admin@abah-krosshealthcare.com

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