3. New Graduate Application

APPLICATION FOR EMPLOYMENT

Med Assist will not share this information with any third party and it is strictly confidential.

1PERSONAL INFORMATION

2EDUCATION & EXPERIENCE

3REQUIRED DOCUMENTATION

4DIRECT DEPOSIT

5EMPLOYEE AGREEMENT ATTESTATION

6POLICY ATTESTATION

7REVIEW APPLICATION

PERSONAL INFORMATION

First Name*

Last Name*

Date of Birth*

Month

Day

Year

Home Address (street and apartment # only)*

City*

State*

Zip Code*

Cell Phone*

(double check your number is accurate before submitting)

Email Address*

(double check your personal email is accurate before submitting)

Social Security*

(double check that your SS is accurate before submitting)

* Indicates Required Field.

EDUCATION & EXPERIENCE

1. Please specify the name of the High School you graduated. (ex; Townsend High School)*

2. Please specify the year of your High School graduation (ex; 2014).*

3. Please specify the name of the college you attended and received your Nursing Degree. (ex; York College)*

4. Please select the highest level of education you obtained in Nursing.

Associate's Degree

Bachelor's Degree

Master's Degree

PhD / Doctorate

5. Are you planning on furthering your education? If so, please select the level of education you plan to pursue.

No plans on furthering my education.

Bachelor's Degree

Master's Degree

PhD / Doctorate

6. Please specify what type of nursing experience you have.

No Experience or recent nursing graduate

Hospital Experience

Homecare Experience (LHCSA or CHHA Agency)

MLTC Experience

Other (School Nurse, Dr. Office, Urgent Care, Dialysis Center, etc)

7. Please list all the languages that you can speak fluently.*

8. Please select two locations where you can conduct IN-PERSON assessments:*

(Select all that apply)

Brooklyn

Queens

Bronx

Manhattan

Staten Island

* Indicates Required Field.

EMPLOYMENT AUTHORIZATION

NYS Drivers License (front only) or a NYS Non-Drivers ID (front only): Color Photos Only (black/white not acceptable)*

*No other IDs are accepted*

Drop files here or

Max. file size: 512 MB, Max. files: 1.

RN REGISTRATION

RN Registration Certificate:*

(Your certificate must be active and cannot be expired, see image to the right for a sample.)

Drop files here or

Max. file size: 15 MB, Max. files: 1.

Sample of an RN Registration Certificate

* Indicates Required Field.

DIRECT DEPOSIT

Name of Bank:*

Account Number:*

Routing Number:*

Attach a voided check:*

Drop files here or

Max. file size: 15 MB, Max. files: 1.

Med Assist is hereby authorized to directly deposit my pay to the account listed above. This authorization will remain in effect until I modify or cancel it in writing.

Signature*

Today's Date

MM slash DD slash YYYY

* Indicates Required Field.

Equipment Agreement

The equipment that will be provided to me is Med Assist's property and it will only be used for work-related purposes.

If I receive a laptop, I will in no way install or remove its software or tamper with any files that I am not responsible for.

In the event that the equipment is lost, stolen, damaged, or is returned not in its original working order, then I shall be solely responsible to pay for its retail value (laptops are $1,200 and smartphones are $800).

In the event that the equipment stops working under reasonable wear and tear conditions, I shall immediately notify my supervisor.

I understand that upon the termination of my employment, I will return the laptop back in its orginal working order within 3 calendar days.

Med Assist has the right to delay my final payment until all equipment is returned. Failure to return will be considered theft and may lead to criminal prosecution.

Non-Competition During & After Termination of Employment

Registered Nurse (RN) hereby agrees not to compete directly or indirectly with business of Med Assist / Nursing Assessment Services (hereby known as Employer) or any of its affiliates within NYC, during the period of employment and for a period of 36 months (3 years) following termination/resignation of employment, notwithstanding the cause of reason for termination/resignation if RN is not employed at least 36 months (3 years) by Employer.

As used herein, non-compete shall mean that the RN shall not own, manage, operate, advise, consult, invest in, be employed in, or otherwise assist a business substantially like, or competitive with, the present business of Employer or any of its affiliates or such other business activity in which Employer or any of its affiliates may engage during the employment of the RN. The HCS User ID shall remain locked by the Employer if the RN is terminated/resigns, notwithstanding the cause of reason for termination or resignation. The RN may not engage in business of employment with another MLTC or UAS Vendor for at least 3 years of employment with Employer.

The non-compete shall remain in effect for three years upon hire. After 36 months of active employment, the non-compete shall become void. Legal action by Employer may be taken if this agreement is breached in any capacity.

Please print, sign, and date below to bind your agreement with the above stipulations.

Employee's Full Name*

(Your first and last name)

Signature*

Today's Date

MM slash DD slash YYYY

* Indicates Required Field.

PTO - Paid Time Off Policy

Employees start to accrue paid time off (PTO) after successful completion of their 90-day probationary period.
Despite having accrued time off, PTO requests will still need to be approved by Management. Management has the right to deny PTO requests based on operational needs.

If an employee wishes to receive pay for their accrued PTO hours upon resignation, the employee must provide a minimum of a 2-week resignation notice.

During the 2-week notice, an employee is NOT allowed to miss any days off or risk losing the payout for their accrued time off.

Sick Leave Policy

If an employee is out sick for 2 or more consecutive days, a note from an MD will be required for the employee to return to work.

Unpaid Leave Policy

If an employee does not have accrued time off, and they need to take off without pay, the organization will only allow a maximum of 5 business for such an absence. Any additional time will result in the employee forfeiting their position and will be terminated.

Employee's Full Name*

(Your first and last name)

Signature*

Today's Date

MM slash DD slash YYYY

{all_fields:noadmin}

Please click on "submit" one-time and wait for the confirmation page.