Advanced Staffing Associates




Are you able to perform the essential job functions of the position for which you are applying with or without reasonable accommodation

Have you been convicted of any felonies other than minor traffic violations during the past seven years (A criminal record or a conviction will not automatically bar employment, but will be considered only as it reasonably relates to your fitness to perform in the position for which you are applying.)

Are you able at time of employment, to submit verification of your legal right to work in the U.S.?

May we contact?  

May we contact?  

May we contact?  

Has your license to practice your profession ever been suspended or revoked?

Have you ever been accused, arrested, or found guilty by any government agency of child, patient, resident, or elderly abuse?

If you are applying for a position involving evening or weekend work, can you fulfill such scheduling requirements?

Are you willing to work overtime and be on call?

Have you ever applied for a position with us?

If you have been given a written job description for the position for which you are applying, which lists the essential functions of the job. Please read it carefully.

Are you able to perform all of the essential functions as set forth in the job description with or without reasonable accommodations?


Start with your present job and include any job related military service assignments. If you need additional space, please continue on a separate piece of paper. Please be sure to list all former employers within the last three years.

May we contact your present Employer?

Previous Employer?


I understand that if employed by Advanced Staffing Associates, and affiliates, I will be an employee at will, which means that I can voluntarily end my employment or be terminated at any time with or without notice for any reason or no reason at all. No statement whether written or oral, by any Company representative may vary the foregoing, I give the Company permission to verify all information provided on the application or in the interview(s), as well as contacting any and all or any of my previous employers and references and authorize them to provide all information requested of them by the Company.

After a conditional offer of employment has been made, if requested by the Company, I agree to take a job-related medical examination including a pre-employment drug test at no personal expense and authorize the examining physician to disclose the findings to the Company. I understand that any offer of employment is conditioned upon receipt of satisfactory references and satisfactory completion of such job-related medical examination and my receipt of negative drug test results.

I have provided truthful and complete responses to all inquiries in the application and understand that the discovery of any false or misleading information or the failure to provide information constitutes a ground for immediate dismissal. If employed, I will abide by the Company’s rules and regulations, which I understand are subject to change by the company.

I have read the foregoing and understand the above. By providing the above authorization I release Advanced Staffing Associates and affiliates from all liability for requesting and acting upon the information, reports and records obtained.

Call us today at 860-747-6406 and allow us to find the professionals for you!

Serving All of Connecticut, at Advanced Staffing Associates we are committed to ensuring that you have a positive experience.