Swift Staffing Agency, Inc.

Relief Specialist Application

Thank you for your interest in joining the Swift team! Please scan this application and email it to AMaid@swiftstaffingagency.com.

Name: _______________________________________________________________________________

                            Last                                                                First                                Middle

Address: _____________________________________________________________________________

            Street                                             Town                                               Zip

Phone: (______)-_______-__________ Emergency Contact Number: (_____)-______-____________

SSN: _________-______-___________ 1099/Tax ID (if applicable):_____________________________

Relationship to Applicant: _____________________________________________________________

Have you previously worked as relief staff? Yes: _______________ No: _______________________

If yes, which agency? __________________________________________________________________

Have you worked with or had life experiences with people  with special needs or other disabilities? If yes, please explain: ______________________________________________________________________________________

______________________________________________________________________________________

Do you have any special certifications or training related to the field? (i.e. PAC, Medication, First Aid/CPR)?

____________________________________________________________________________________________________________________________________________________________________________

How did you learn of Swift Staffing Agency? ____________________________________________________________________________________________________________________________________________________________________________

REFERENCES

Please give three (3) references of people such as former employers, colleagues or those acquainted with you, but not who are related to you.

1. Name: _________________________________________________________________________

Phone: (_____)-_______-__________ Email: _________________________________________

Occupation: ___________________________________________________________________

2. Name: _________________________________________________________________________

Phone: (_____)-_______-__________ Email: _________________________________________

Occupation: ___________________________________________________________________

3. Name: _________________________________________________________________________

Phone: (_____)-_______-__________ Email: _________________________________________

Occupation: ___________________________________________________________________

WORK HISTORY

1.) Company Name: ____________________________________________________________________

      Company Address: __________________________________________________________________

      Employed from ______/___________/_________ to___________/___________/________________

      Immediate Supervisor: ______________________________________________________________

      Reason(s) for Leaving: _______________________________________________________________

2.) Company Name: ___________________________________________________________________

      Company Address:
        _______________________________________________________________________________

      Employed from ______/___________/_________ to___________/___________/________________

      Immediate Supervisor: ______________________________________________________________

      Reason(s) for Leaving: _______________________________________________________________

3.) Company Name: ___________________________________________________________________

      Company Address: __________________________________________________________________

      Employed from ______/___________/_________ to___________/___________/________________

      Immediate Supervisor: ______________________________________________________________

      Reason(s) for Leaving: _______________________________________________________________

ACADEMIC RECORD
1.) High School: _______________________________________________________________________

      Address: ___________________________________________________________________________

      Graduate? Yes _______ No _________ If yes, Date: _______________________________________

2.) College/Universities: _______________________________________________________________

       Address: ___________________________________________________________________________

       Major/Minor: ______________________________________________________________________

      Graduate? Yes ______ No ________ If yes, Date: _________________________________________

3.) Vocational/Business Schools:________________________________________________________

      Address: ___________________________________________________________________________

      Graduate? Yes _______ No _________ If yes, Date: _______________________________________

AVAILABILITY

Full-Time Relief: ______

Part-Time Relief: ______

Days: ___ Nights: ____ Overnights: ____ Weekends: ____ Weekdays: ____ Holidays: ____

Can we call you if a shift becomes available last minute? Yes ______ No _______

Swift Staffing Agency will make every attempt to ensure that you are able to work in the communities that you want, however, we cannot promise this due to the needs of the individuals.

With my signature, I acknowledge all of the following:

1. The information on all pages of this application is completed and accurate.
2. Swift Staffing Agency will verify the above information and will contact the above references.
3. A Criminal Offender Record Information (CORI) investigation and a Disabled Persons Protection Commission Abuser Registry Search Consent Form will be completed on all individuals who are hired to work for the Swift Staffing Agency.

Signature: _____________________________________________________________________

Date: __________________________________________________________________________