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Top Echelon Contracting - The Recruiters Back-Office Solution

Pre-Hire Application for Therapy Professionals


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Personal
Last Name   First   Middle  
Street Address  
Home Telephone  
 
Apartment Number, P.O. Box, etc
City   State Zip  
 
Social Security Number
E-mail Address     Homepage Address
Alternate Phone (cell, pager)
Have you ever applied for employment with Top Echelon Contracting?
- Month/Year: (mm/yyyy)                   
Date of Birth    
(mm/dd)
Which PediaStaff recruiter referred you to Top Echelon Contracting's Pre-Hire Application? Maiden Name (if applicable) 
Are you interested in opting into the Extra Eight Summer Pay Plan Program?
For further details click here.

Education
School Name, City & State of School Course of Study Did You Graduate?
Graduate 
City
State

College / University  
City
State

Trade / Technical  
City
State

High School    
City
State

Licensure 
If licensure is a requirement for employment in the State you will be working, you will NOT be able to start work until all documentation is provided to Top Echelon Contracting.
Licensure State Number Exp. Date
(mm/dd/yyyy)   
(mm/dd/yyyy)   
(mm/dd/yyyy)   
(mm/dd/yyyy)   

Employment
Please give accurate, complete full-time and part-time employment record. Start with your present or most recent employer.
Company Name  
Employed (month/year)
From    To
Address City
State
Phone
Reason for Leaving
Job Title
Supervisor
May We Contact This Employer?
 
Company Name  
Employed (month/year)
From    To
Address City
State
Phone
Reason for Leaving
Job Title
Supervisor
May We Contact This Employer?
 
Company Name  
Employed (month/year)
From    To
Address City
State
Phone
Reason for Leaving
Job Title
Supervisor
May We Contact This Employer?
 
Company Name  
Employed (month/year)
From    To
Address City
State
Phone
Reason for Leaving
Job Title
Supervisor
May We Contact This Employer?

References / Background
Have you ever been convicted of a crime or felony in the past ten years, excluding misdemeanors and summary offenses?
   
If yes, describe in full.  
Have you ever been fingerprinted by the FBI? If yes, what month and year were your fingerprint results dated?
    Month / Year (mm/yyyy)     

Signature
Please read the following carefully before signing.
By signing below, I certify that I have read, understand and agree to each of the following statements:

I acknowledge that by completing and submitting this application to your company, there is no guarantee of an interview or job offer. I also understand that my application may be considered with others who have applied for the same position, and that your company may interview and/or hire applicants whose qualifications most closely meet the position requirements.

I affirm that all of the information I have supplied on this application is true, accurate and complete to the best of my knowledge, and I have not knowingly withheld any information which, if known by your company, would affect my application unfavorably.

I acknowledge that if I am hired your company, and if your company discovers at any time during my employment that any of the statements or answers on this application are false, misleading, or incomplete, I may be dismissed immediately from my job.

I agree to submit to a medical examination, which may include testing for drugs or alcohol prior to beginning work with your company. I understand that if I am employed by your company, I may be required, when consistent with your business needs and employment handbook, to undergo a medical examination including drug and/or alcohol testing.

I acknowledge that if I am hired, I will be required to abide by all of your company’s rules and regulations. I also understand that your company is a smoke free environment.

I understand that nothing in this employment application creates an express or implied contract of employment between your company and me. If I am hired by your company, my employment and compensation are "at will", which means that my employment can be terminated, either by your company or me, with or without cause, and with or without notice. I understand that if I am hired, none of your managers or supervisors have authority to make an express or implied employment contract with me, either orally or in writing, that changes or alters the "at will" nature of my employment.

I agree to release to your company and/or its designated agents all medical information, including but not limited to files, reports, x–rays, evaluations, and opinions held by medical personnel, to the extent such information is job–related and consistent with your company’s business needs. I acknowledge that this is a general release and that if hired, it remains in effect for the duration of my employment.

In the event of my personal indebtedness to your company, I authorize your company to withhold from my wages such amounts as permitted by law to satisfy my obligation to your company.

I give my permission to conduct any investigation regarding the information contained in my employment application, which your company determines is necessary to verify my qualifications for assuming a job with your company. I give your company my permission to contact any of the following: Former employer, school, college or university, any personal or professional reference, or any other appropriate source or individual for the purpose of gathering any information, personal or otherwise, that such sources may have about my character, general reputation, education or employment record, criminal background, and/or credit history. I give my consent to any such source to release to your company whatever information they have about me. I also unconditionally release all named and unnamed sources from any liability that might result from furnishing any information about me.

I authorize Top Echelon Contracting, Inc. to investigate my background. I acknowledge that reference checks will involve the collection of various sources of information, including, without limitation, current and former employers’ records, educational records, and professional & personal references. I request, authorize, and consent to the release and disclosure of any and all information, about me to Top Echelon Contracting. I understand that these reports may contain information about my background, mode of living, character, personal characteristics and general reputation. I also unconditionally release all named and unnamed sources from any liability that might result from furnishing any information about me.

This authorization in original or copy form shall be valid from the date indicated next to my typed name until the termination of my employment with Top Echelon Contracting.

I certify that by typing my name below I have read and agree to the terms above.

Full Name   
Date 
(mm/dd/yyyy)