Job Application | Medflex Staffing Services

Complete a Job Application

Medflex Staffing Services in Wichita, Kansas, is an Equal Opportunity Employer (EOE). If you would like to be included within our database of staff that is available for daily (PRN) staffing, contract/travel staffing, contract to hire or permanent placement, please complete the application.

Personal Information

Full Name:(Required)

First Last

Email:(Required)

Phone:(Required)

Address:(Required)

Street Address Address Line 2 City State ZIP Code

Number of Years at This Address:(Required)

Daytime Phone:

Evening Phone:

Mobile Phone:

Driver's License (State/Number):

Emergency Contact

Who should be contacted if you are involved in an emergency?

Contact Name:

First Last

Relationship to You:

Address:

Street Address Address Line 2 City State ZIP Code

Daytime Phone:

Evening Phone:

Professional Information

Upload Resume/Cover Letter:(Required)

Drop files here or

Max. file size: 256 MB.

Link to Website or Online Profile:

Applicant Information

Job Position Applied For:

Full or Part Time?

Full Time

Part Time

If hired, are you able to submit proof that you are legally eligible for employment in the United States?

Yes

Applicant Employment History

List your current or most recent employment first. Please list all jobs (including self-employment and military service) which you have held, beginning with the most recent, and list and explain any gaps in employment.

First Employer Name:

Supervisor Name:

Address:

Street Address Address Line 2 City State ZIP Code

Job Duties:

Reason for Leaving:

Start Date of Employment:

(Month/Year)

End Date of Employment:

(Month/Year)

Second Employer Name:

Supervisor Name:

Address:

Street Address Address Line 2 City State ZIP Code

Job Duties:

Reason for Leaving:

Start Date of Employment:

(Month/Year)

End Date of Employment:

(Month/Year)

Third Employer Name:

Supervisor Name:

Address:

Street Address Address Line 2 City State ZIP Code

Job Duties:

Reason for Leaving:

Start Date of Employment:

(Month/Year)

End Date of Employment:

(Month/Year)

Applicant's Education and Training

College/University Name:

Address:

Street Address Address Line 2 City State ZIP Code

Did you receive a degree?

Yes

If Yes, Degree(s) Received:

High School/GED Name:

Address:

Street Address Address Line 2 City State ZIP Code

Did you receive a degree?

Yes

Other Training (graduate, technical, vocational):

Please indicate any current professional licenses or certifications that you hold:

Awards, Honors, Special Achievements:

References

Please provide three professional references below.

Full Name of First Reference:(Required)

Relationship:(Required)

Phone:(Required)

Company:(Required)

Address:(Required)

Street Address Address Line 2 City State ZIP Code

Full Name of Second Reference:(Required)

Relationship:(Required)

Phone:(Required)

Company:(Required)

Address:(Required)

Street Address Address Line 2 City State ZIP Code

Full Name of Third Reference:(Required)

Relationship:(Required)

Phone:(Required)

Company:(Required)

Address:(Required)

Street Address Address Line 2 City State ZIP Code

Disclaimer and Signature

Please provide any other information that you believe should be considered, including whether you are bound by any agreement with any current employer:

In signing and submitting this application for employment to you (the Company), I clearly understand and agree: (1) I certify that the information contained in this application is correct and complete to the best of my knowledge and understand that any omission, misrepresentation or falsification of information made herein or in any interviews is grounds for refusal to employ me or my dismissal if I am employed; (2) I authorize the references listed above, schools and current and past employers to give the Company any and all information concerning my previous employment and any information they may have, personal or otherwise, and I release all parties from all liability for any damage or claim that may result from furnishing the same to the Company; (3) If I am employed, I agree to abide by the rules, regulations and policies of the Company, and my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at the option of either the Company or myself; (4) I understand that no representative of the Company, other than a Managing Partner of the Company, has any authority to enter into any agreement for employment for any specified period of time, or make any agreement contrary to the foregoing.

Signature

Date

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