MNR Staffing Attestation and Acceptance of Terms

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Please complete the form below. Once completed the system will email you a pdf copy of the form and your answers. If you have any questions, please contact us.
   
Name
Email
   
Have you ever been convicted of a felony or misdemeanor?
Yes No
If yes, please explain:
   
Have you ever been, or are you now, party to any malpractice or negligence actions?
Yes No
If yes, please explain:
   
Have you ever been terminated, disciplined, suspended or discharged by any previous employers?
Yes No
If yes, please explain:
   
Have you held a nursing license under any other name?
Yes No
If yes, please provide name, state and license number:
   
Has your professional license from any jurisdiction ever been investigated, suspended, revoked or placed on probation?
Yes No
If yes, please explain:
   

GUARANTEE OF EMPLOYMENT
MNR Staffing does not guarantee that we will locate positions for all candidates. By submitting information to us you agree that we will use that information in an effort to locate a position on your behalf, however we cannot guarantee placement for all candidates. All hiring decisions are made by client facilities and not MNR Staffing. MNR Staffing does not employee candidates directly, all positions are direct-hire positions at client facilities.

TERMS AND CONDITIONS
I attest that all information provided to MNR Staffing is complete and accurate, to the best of my knowledge. Providing incomplete or inaccurate information may result in disqualification from possible employment with MNR Staffing clients, and may be a violation of state law(s) that could result in civil penalties. MNR Staffing is authorized to obtain information from my current and previous employers, and to release information in support of my application (application, references, background search results, etc.) to client institutions and to appropriate governmental or licensing entities. MNR Staffing may also share applicant information with its affiliates.

BACKGROUND CHECKS
I understand that MNR Staffing, certain states and/or client institutions may require criminal background checks, and I consent to such checks. Prior to conducting any background checks that qualify as consumer or investigative consumer reports, I will be provided and will return, separate disclosure and acknowledgement forms as required by MNR Staffing or its clients. I also give permission for the release of the results for determining the fitness of employment.

EMPLOYMENT AND MEDICAL INFORMATION RELEASE
I authorize MNR Staffing, to release any and all confidential employment and medical information contained in my employment file to any medical facility or entity with whom MNR Staffing has an agreement, and to any other governmental or regulatory agency at such agency’s request. For all other purposes, MNR Staffing shall keep my employment and medical records confidential. I hereby hold MNR Staffing harmless for any result(s) that arise with regards to the release of this confidential information by MNR Staffing.

CHOICE OF LAW
This agreement will be construed in all respects according to the laws of the state of Connecticut.

CONFIDENTIALITY OF AGREEMENT
MNR Staffing and Applicant will maintain the confidentiality and exclusivity of this Agreement.

AGREEMENT REVIEW
MNR Staffing and Applicant agree that each party has fully read and reviewed this Agreement and should any ambiguities arise, the interpretation of the ambiguity will not automatically be that of the Applicant.

EQUAL OPPORTUNITY EMPLOYER
MNR Staffing is an equal opportunity company. MNR Staffing does not discriminate in respect to terms and conditions of privileges of employment on the basis of race, color, national origin, sex, age or related medical conditions, or disability.

NOTICES
Any notices, which are required or permitted will be in writing and will be, deemed properly delivered to the other party when sent U.S. Mail, certified, postage prepaid and addressed to the following:

MNR Staffing LLC
410A-262 Queen Street
Southington, CT 06489
 
I attest all answers given herein are true and complete to the best of my knowledge.
(Please type your name in the box below, it acts as your signature.)
Signature