Dear Applicant,
Thank You for choosing Aspire Medical Staffing
As you know, all of our clients require that we send them your specific credentials. These credentials are necessary to meet the facility regulations. Please complete all the following documents and return with the requested documents below. If these forms are not returned in a timely manner it may delay us in placing you on an assignment.
Return to Aspire Medical Staffing all of the documents below:
  1. Copy of your license/certificate if available
  2. Copy of your malpractice insurance if available
  3. PPD Test
  4. Current Physical within the last 12 months
  5. Titer lab results indicating immunity to the following: (Required for Nurses)
    1. Measles (Rubeola) (if born after 1957)
    2. Mumps
    3. Rubella
    4. Varicella
    5. Other( specify)Other( specify)
  6. Resume
  7. W-4 Form
  8. I-9 Form with two forms of identification (usually a passport is sufficient, or driver’s license and social security card)
  9. Completed skills checklist(s) (see enclosed)
  10. Proof of current CPR, BCLS, PALS, or ACLS certifications
You can email, fax or mail completed forms to Aspire Medical Staffing. Please feel free to call us with any- questions. Our office hours are Monday – Friday from 9am to 5pm. Remember to keep us informed about your availability so we can call you for assignments!
Aspire Medical Staffing
Phone: (980) 298-6391
Fax: (980) 500-0123
info@aspiremedstaff.com

EMPLOYMENT APPLICATION

Name
Home Tel
Street Address
Cell
City, State, Zip
E-Mail
Social Security No:
Other (Specify):
Position Applying For:
Salary Desired:

WORK HISTORY:

Current or Last Employer
Street Address
City, State, Zip
Reason for Leaving
Tel.
Dates Worked – From To
Supervisor
Job Title
Name Used While Employed
Duties
May we contact this employer for a reference?yesno
Prior Employer
Street Address
City, State, Zip
Reason for Leaving
Tel.
Dates Worked – From To
Supervisor
Job Title
Name Used While Employed
Duties
May we contact this employer for a reference?yesno

EDUCATION

High School
Street Address
City, State, Zip
Name Used While Attending
College/Nursing School
Street Address
City, State, Zip
Degree/Course/Certificate
Date Received
Were You Ever Convicted Of A Crime?yesno
If Yes, Please Explain
* Criminal conviction(s) will not automatically disqualify an applicant from employment with (Aspire Medical Staffing)

PLEASE READ AND SIGN
I hereby authorize (Aspire Medical Staffing), and also authorize and request each former employer and person, firm or corporation given as a reference to answer all questions that may be asked and give all information that may be sought in connection with this application specifically concerning my work, skill or my professional performance and reliability in the form or a reference. My employment with (Aspire Medical Staffing) will not begin until such references are received.

I agree, in consideration of your employing me that I will not seek or accept employment from any client of (Aspire Medical Staffing) without first obtaining permission from (Aspire Medical Staffing). I understand that if I am in violation of this agreement, I am subject to legal action and monetary damages up to 30% of my annual salary provided by the client if I was employed by that facility as a permanent full -time employee. In addition, I agree not to switch over to the payroll of a competing agency when I am placed at a facility through (Aspire Medical Staffing) without the approval of (Aspire Medical Staffing).

I understand that this employment application is not a contract and that if hired, my employment with (Aspire Medical Staffing) can be terminated with or without cause, and with or without notice, at any time, at the option of (Aspire Medical Staffing) I also understand that any and all benefits received pursuant to employment with (Aspire Medical Staffing) may be changed or eliminated at will without prior notice.

I consent to having a criminal background check done on my history, including a social security number verification, and I understand that my employment might hinge on this check, including termination if after I am hired, (Aspire Medical Staffing) information is acquired that precludes my employment with Aspire Medical Staffing.

I understand that all applicants may be required to pass screening for the presence of illegal drugs or alcohol as a condition of employment at (Aspire Medical Staffing). I may be required to voluntarily submit to a urinalysis test at a laboratory chosen by the company and by signing this consent agreement I release (Aspire Medical Staffing) from liability. I understand that with positive test results I will be denied employment at this time, but I may initiate another inquiry with (Aspire Medical Staffing), after 6 months provided that a drug retest is performed and negative results are received. (Aspire Medical Staffing), will not discriminate against applicants for employment because of past abuse of alcohol/drugs as long as a current drug test is positive However, (Aspire Medical Staffing) will not tolerate the current abuse of alcohol/drugs I may also be asked to voluntarily submit to urinalysis tests for post incident screening and random drug testing at any time in the future due to a past Positive Drug test. Criminal background screening and/or Drug testing are conducted when clients who are interested in hiring me require these tests or if it is a requirement of the Department of Health/ Public Health in the states the agency operates in. Additionally, some states require that Medical Staffing Companies be licensed as a medical staffing agency. The licenses in some of these states may require that all employees have criminal background checks and or drug testing.
The representative of (Aspire Medical Staffing) will inform me of the regulations about criminal background checking and drug testing.

I authorize (Aspire Medical Staffing) to copy and forward my personnel file contents to any and all client facilities which require this of (Aspire Medical Staffing). I hereby certify that all of the above information is true and correct. I understand that any misrepresentation or false information given on this application will result in rejection or termination of employment.

I authorize the obtaining of references.

Print Name:
Date:

HEPATITIS B STATUS DECLARATION

Do not sign both the Acceptance and Declination portions of this form. If you have any uncertainty regarding your current status, please contact your Aspire Medical Staffing representative for clarification. If you are unable to provide the required vaccination information at this time, please sign the declination portion of this document.

Hepatitis B Declination

I understand that my occupation may result in exposure to blood or other potentially infectious materials, and that I may be at risk of acquiring Hepatitis B Virus (HBV) infection. I understand that my failure to receive this vaccine may subject me to the risk of acquiring Hepatitis B disease or, I am in the process of receiving inoculations for Hepatitis, but I have not completed them yet. Therefore, for now I decline and I will furnish you proof of my inoculations when they are completed.
Print Name:
Date:
Social Security Number

Hepatitis B Acceptance

I have already received 3 vaccinations required for Hepatitis B Vaccination Series and I am able to provide the vaccination records as proof of these inoculations at this time.
Print Name:
Date:
Social Security Number

REFERENCE REQUEST

I hereby authorize the release of my employment and performance records to Aspire Medical Staffing. I respectfully request your prompt response to this request as my future employment is dependent on your contribution.

Employer Contact Information

Facility Name
Unit
Address
Contact Name
Title
Phone
Fax
Email

Employee Information

Name of Applicant (printed)
Name used while employed
Position
Social Security #
Dates of Employment: From To
Date

This portion is to be completed by the Employer

Quality of work / CompetencyEXCELLENTGOODAVERAGEPOOR
Attendance / PunctualityEXCELLENTGOODAVERAGEPOOR
Professional ConductEXCELLENTGOODAVERAGEPOOR
Cooperation /RelationshipsEXCELLENTGOODAVERAGEPOOR
Comments:
Eligible for Rehire:YESNO
Still Currently Employed:YESNO
Sincerely,Name(printed)
Date
Title
Direct Number
Aspire Medical Staffing recognizes the many tasks you must accomplish daily. We appreciate the moments you spent completing this request.
Please return this document to our offices via email or fax

Employment Eligibility Verification

Department of Homeland Security

U.S. Citizenship and Immigration Services

START HERE:Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form.
ANTI-DISCRIMINATION NOTICE:It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.

Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.)

Last Name (Family Name)
First Name (Given Name)
Middle Initial
Other Last Names Used (if any)
Address (Street Number and Name)
Apt. Number
City or Town
State
ZIP Code
Date of Birth (mm/dd/yyyy)
U.S. Social Security Number
Employee's E-mail Address
Employee's Telephone Number
I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents inconnection with the completion of this form.
I attest, under penalty of perjury, that I am (check one of the following boxes):
1. A citizen of the United States
2. A noncitizen national of the United States (See instructions)
3. A lawful permanent resident (Alien Registration Number/USCIS Number):
4. An alien authorized to work until(expiration date, if applicable):
Some aliens may write "N/A" in the expiration date field. (See instructions)
Aliens authorized to work must provide only one of the following document numbers to complete Form I-9:
An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.
1. Alien Registration Number/USCIS Number:

OR

2. Form I-94 Admission Number:

OR

3. Foreign Passport Number:
Country of Issuance:
Today's Date

Preparer and/or Translator Certification (check one):

I did not use a preparer or translator.A preparer(s) and/or translator(s) assisted the employee in completing Section 1.
(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)
I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.
Today's Date
Last Name (Family Name)
First Name (Given Name)
Address (Street Number and Name)
City or Town
State
ZIP Code

Employment Eligibility Verification

Department of Homeland Security

U.S. Citizenship and Immigration Services

Section 2. Employer or Authorized Representative Review and Verification

(Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.")
Employee Info from Section 1
Last Name (Family Name)
First Name (Given Name)
M.I.
Citizenship/Immigration Status
  • List A
  • OR
  • List B
  • AND
  • List C

Identity and Employment Authorization

Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Additional Information

Identity

Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Additional Information

Employment Authorization

Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Additional Information
Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine
The employee's first day of employment (mm/dd/yyyy): (See instructions for exemptions)
Today's Date(mm/dd/yyyy)
Title of Employer or Authorized Representative
Last Name of Employer or Authorized Representative
First Name of Employer or Authorized Representative
Employer's Business or Organization Name
Employer's Business or Organization Address (Street Number and Name)
City or Town
State
ZIP Code

Section 3. Reverification and Rehires(To be completed and signed by employer or authorized representative.)

A.New Name (if applicable)

Last Name (Family Name)
First Name (Given Name)
Middle Initial

B.Date of Rehire (if applicable)

Date (mm/dd/yyyy)

A.If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below.

Document Title
Document Number
Expiration Date (if any) (mm/dd/yyyy)
I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual.
Today's Date (mm/dd/yyyy)
Name of Employer or Authorized Representative

Employee’s Withholding Certificate

Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay.
Give Form W-4 to your employer.
Your withholding is subject to review by the IRS.

Step 1:Enter Personal Information

a) First name and middle initial
Last name
Address
City or town, state, and ZIP code
b) Social security number
Does your name match the name on your social security card? If not, to ensure you get credit for your earnings, contact SSA at 800-772-1213 or go to www.ssa.gov.
c)Single or Married filing separately
Married filing jointly (or Qualifying widow(er))
Head of household (Check only if you’re unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual.)
Complete Steps 2–4 ONLY if they apply to you; otherwise, skip to Step 5. See page 2 for more information on each step, who can claim exemption from withholding, when to use the online estimator, and privacy.

Step 2: Multiple Jobs or Spouse Works

Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spouse also works. The correct amount of withholding depends on income earned from all of these jobs.
Do only one of the following.
(a) Use the estimator at www.irs.gov/W4App for most accurate withholding for this step (and Steps 3–4); or
(b)Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below for roughly accurate withholding; or
(c)If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This optionis accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld . . . . . .
Tip: To be accurate, submit a 2020 Form W-4 for all other jobs. If you (or your spouse) have self-employment income, including as an independent contractor, use the estimator.
Complete Steps 3–4(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will be most accurate if you complete Steps 3–4(b) on the Form W-4 for the highest paying job.)

Step 3: Claim Dependents

If your income will be $200,000 or less ($400,000 or less if married filing jointly):
Multiply the number of qualifying children under age 17 by $2,000 $
Multiply the number of other dependents by $500 . . . . $
Add the amounts above and enter the total here . . . . . . . . . . . . . $

Step 4 (optional): Other Adjustments

(a) Other income (not from jobs). If you want tax withheld for other income you expect this year that won’t have withholding, enter the amount of other income here. This may include interest, dividends, and retirement income . . . . . . . . . . . . $
(b) Deductions. If you expect to claim deductions other than the standard deduction and want to reduce your withholding, use the Deductions Worksheet on page 3 and enter the result here . . . . . . . . . . . . . . . . . . . . . $
(c) Extra withholding. Enter any additional tax you want withheld each pay period . $

Step 5: Sign Here

Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete.
Date

Employers Only

Employer’s name and address
First date of employment
Employer identification number (EIN)

For Privacy Act and Paperwork Reduction Act Notice

General Instructions

Future Developments

For the latest information about developments related to Form W-4, such as legislation enacted after it was published, go to www.irs.gov/FormW4.

Purpose of Form

Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. If too little is withheld, you will generally owe tax when you file your tax return and may owe a penalty. If too much is withheld, you will generally be due a refund. Complete a new Form W-4 when changes to your personal or financial situation would change the entries on the form. For more information on withholding and when you must furnish a new Form W-4, see Pub. 505.

Exemption from withholding. You may claim exemption from withholding for 2020 if you meet both of the following conditions: you had no federal income tax liability in 2019 and you expect to have no federal income tax liability in 2020. You had no federal income tax liability in 2019 if (1) your total tax on line 16 on your 2019 Form 1040 or 1040-SR is zero (or less than the sum of lines 18a, 18b, and 18c), or (2) you were not required to file a return because your income was below the filing threshold for your correct filing status. If you claim exemption, you will have no income tax withheld from your paycheck and may owe taxes and penalties when you file your 2020 tax return. To claim exemption from withholding, certify that you meet both of the conditions above by writing “Exempt” on Form W-4 in the space below Step 4(c). Then, complete Steps 1(a), 1(b), and 5. Do not complete any other steps. You will need to submit a new Form W-4 by February 16, 2021.

Your privacy. If you prefer to limit information provided in Steps 2 through 4, use the online estimator, which will also increase accuracy.

As an alternative to the estimator: if you have concerns with Step 2(c), you may choose Step 2(b); if you have concerns with Step 4(a), you may enter an additional amount you want withheld per pay period in Step 4(c). If this is the only job in your household, you may instead check the box in Step 2(c), which will increase your withholding and significantly reduce your paycheck (often by thousands of dollars over the year).

When to use the estimator. Consider using the estimator at www.irs.gov/W4App if you:
1. Expect to work only part of the year;
2. Have dividend or capital gain income, or are subject to additional taxes, such as the additional Medicare tax;
3. Have self-employment income (see below); or
4. Prefer the most accurate withholding for multiple job situations.

Self-employment. Generally, you will owe both income and self-employment taxes on any self-employment income you receive separate from the wages you receive as an employee. If you want to pay these taxes through withholding from your wages, use the estimator at www.irs.gov/W4App to figure the amount to have withheld.

Nonresident alien. If you’re a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form.

Specific Instructions

Step 1(c). Check your anticipated filing status. This will determine the standard deduction and tax rates used to compute your withholding.
Step 2. Use this step if you (1) have more than one job at the same time, or (2) are married filing jointly and you and your spouse both work.
Option (a) most accurately calculates the additional tax you need to have withheld, while option (b) does so with a little less accuracy.

If you (and your spouse) have a total of only two jobs, you may instead check the box in option (c). The box must also be checked on the Form W-4 for the other job. If the box is checked, the standard deduction and tax brackets will be cut in half for each job to calculate withholding. This option is roughly accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld, and this extra amount will be larger the greater the difference in pay is between the two jobs.

CAUTION

Multiple jobs. Complete Steps 3 through 4(b) on only one Form W-4. Withholding will be most accurate if you do this on the Form W-4 for the highest paying job.

Step 3. Step 3 of Form W-4 provides instructions for determining the amount of the child tax credit and the credit for other dependents that you may be able to claim when you file your tax return. To qualify for the child tax credit, the child must be under age 17 as of December 31, must be your dependent who generally lives with you for more than half the year, and must have the required social security number. You may be able to claim a credit for other dependents for whom a child tax credit can’t be claimed, such as an older child or a qualifying relative. For additional eligibility requirements for these credits, see Pub. 972, Child Tax Credit and Credit for Other Dependents. You can also include other tax credits in this step, such as education tax credits and the foreign tax credit. To do so, add an estimate of the amount for the year to your credits for dependents and enter the total amount in Step 3. Including these credits will increase your paycheck and reduce the amount of any refund you may receive when you file your tax return.

Step 4 (optional).

Step 4(a). Enter in this step the total of your other estimated income for the year, if any. You shouldn’t include income from any jobs or self-employment. If you complete Step 4(a), you likely won’t have to make estimated tax payments for that income. If you prefer to pay estimated tax rather than having tax on other income withheld from your paycheck, see Form 1040-ES, Estimated Tax for Individuals.

Step 4(b). Enter in this step the amount from the Deductions Worksheet, line 5, if you expect to claim deductions other than the basic standard deduction on your 2020 tax return and want to reduce your withholding to account for these deductions. This includes both itemized deductions and other deductions such as for student loan interest and IRAs.

Step 4(c). Enter in this step any additional tax you want withheld from your pay each pay period, including any amounts from the Multiple Jobs Worksheet, line 4. Entering an amount here will reduce your paycheck and will either increase your refund or reduce any amount of tax that you owe.

Sample: Agency may need to use similar form provided by their payroll processing vendor.

Authorization Agreement

I hereby authorize [Company Name] to initiate automatic deposits to my account at the financial institution named below. I also authorize [Company Name] to make withdrawals from this account in the event that a credit entry is made in error.

Further, I agree not to hold [Company Name] responsible for any delay or loss of funds due to incorrect or incomplete information supplied by me or by my financial institution or due to an error on the part of my financial institution in depositing funds to my account.

This agreement will remain in effect until [Company Name] receives a written notice of cancellation from me or my financial institution, or until I submit a new direct deposit form to the Payroll Department.

Account Information

Name of Financial Institution:
Routing Number:
Account Number:

Signature

Authorized Signature (Primary):
Date:
Authorized Signature (Joint):
Date:
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