Apply Now UNI-STAFF REGISTRY Employment Application1937 Pontius Ave. Los Angeles, CA 90025 Programs services and employment are available equally to everyone. The company does not discriminate on the basis of race, religious creed, color, national origin, ancestry, physical disability, mental disability, medical condition, marital status, sex, age, or sexual orientation of any person, in its employment practices. Please inform the Human Resources Department if you require reasonable accommodation to the application or interview.General InformationFull Name *Last, First MiddleEmail *Position Applying for *Location (you may choose more than one location) FairfieldFillmoreFullertonJacksonMonthclairPasadenaSan BernardinoSan JoseSouthgateHome Health Traveling NurseAddress Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalestinian TerritoryPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWestern SaharaWestern SamoaYemenZambiaZimbabweCountryHome Phone Mobile Phone Social Security # If no, please explain Race Do not wish to disclosedWhiteBlack or African AmericanAsianHispanic or LatinoAmerican Indian or Alaska NativeTwo or more racesNative Hawaiian/Other Pacific IslanderCan you, at the time of hire, submit verification of your legal right to work in the U.S.? YesNoNote Company will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of Article 9 of Chapter XVIII of the Los Angeles Municipal Code; Ordinance 184652.Employment DesiredDate available to start Rate of expected pay Shift available AnyAMPMNOCEmployment desired Full-TimePart-TimePer Diem/On CallTemporaryHow many hours per week are you able to work Weekend Availability SaturdaySundayN/AEducationHigh School City/State # of Years Completed Did you graduate? YesNoCollege/University City/State # of Years Completed Did you graduate? YesNoDegree Major Others City/State: # of Years Completed: Did you graduate? YesNoDegree Major Previous Employment (Begin With The Most Recent Position)I. Date of Employment From To Position(s) Held Company Address Phone Supervisor Title Responsibilities Starting Title Ending Title Reason for Leaving May we contact this employer for reference? YesNoSectionII. Date of Employment From To Position(s) Held Company Address Phone Supervisor Title Responsibilities Starting Title Ending Title Reason for Leaving May we contact this employer for reference? YesNoSectionIII. Date of Employment From To: Position(s) Held Company Address Phone Supervisor Title: Responsibilities Starting Title Ending Title Reason for Leaving May we contact this employer for reference? YesNoProfessional ReferencesReference 1 Name Occupation Phone SectionReference 2 Name Occupation Phone SectionReference 3 Name Occupation Phone Statement of CertificationInstructions Electronic Signature (type in your full name) Date VerificationPlease enter any two digits *Example: 12This box is for spam protection - <strong>please leave it blank</strong>:
