Employment Application
PERSONAL DATA
Last Name
Today''s Date
Date Available to Work
First Name
Middle Soc Sec Num Home Phone
Cell Phone/Pager
STREET ADDRESS
Unit CITY
STATE
ZIP
EMAIL
PREVIOUS STREET ADDRESS:
Unit CITY
STATE
ZIP
BEST TIME TO CALL
Name of Emergency Contact
Relation
Emergency Phone Number
JOB INFORMATION :
POSITION APPLYING FOR
RN
NP
LP/VN
CST
ST
Tech
Allied
CNA/NA
Other
WORK EXPERIENCE/SKILLS
Please check the boxes where you have gained at least 1 year of experience and are clinically competent to work
Burn
Ent
Pediatrics
Detox/Drug
L & D
Rehab
Telemetry
Post Partum
MICU
Nursery
Psychiatry
Orthopedics
NICU
Dialysis
Mother/Baby
Step Down
PACU
Geriatric
SICU
Oncology
Neurology
Emergency Room
Pedi UICU
Med/Surg
CCU
TYPE OF WORK DESIRED: CHECK ALL THAT APPLY
:
Hospital
Recover Room
Open Heart
Operating Room
Other Speciality
Clinic
Hospice
Nursing Home
Rehab
Private Duty
Psychiatric
Assisted Living or Residential Treatment
L
ANGUAGE SKILLS
:
Other than English, please check any other languages you speak.
Spanish
French
German
Other
Part-Time
Check the days of the week you are available to work:
Sunday
Check the shift(s) you prefer below
Contract
Travel
Perm-Placement
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
7AM-3PM
3PM-11PM
11PM-7AM
7AM-7PM
7PM-7AM
Other
Education and Training
:
(Please list all schools attended) Begin with high schools, and then list all colleges, vocational/military service schools.
High School Name
Street Address
Highest Grade Completed
City ST Zip
Country
College/Vocational School
Street Address
City St ZIP
Country
Major Emphasis
Degree Completed Level and Type
Page 1 of 5
Check the type of assignment you are available for
:
Full-Time
License/Certification
License Type
License/Certification No
State
Expiration Date
License Type
License/Certification No
State
Expiration Date
License Type
License/Certification No
State
Expiration Date
Has your license ever been suspended, revoked or under investigation ?
No
Yes
If Yes, explain
Certifications: Check all applicable certifications and list expiration date(s)
ACLS
Expiration Date
IV
Expiration Date
BCLS
Expiration Date
NALS
Expiration Date
CPR
Expiration Date
Other
Expiration Date
PALS
Expiration Date
Are you legally authorized to work in the USA?
No
Yes
If No, are you interested in being sponsored to work in the U.S?
Note: If yes, you must commit to at least 3 years.
No
Yes
Enter approximate date you are available to immigrate to the U.S.
Should you become employed by our company, you will be required to provide the documentation proving your eligibility to work in the U.S.
Have you ever been convicted of a felony?
No
Yes
Have you ever been convicted of a misdemeanor?
No
Yes
Have you ever been employed by Our Company or any of its subsidiaries?
No
Yes
If yes give location(s) and dates
Have you ever interviewed with Our Company or any of its subsidiaries?
No
Yes
If yes, when and at what location?
How were you referred?
Trade Publication
Job Fair/Open House
Other Source
Our Company Employee
Employee Name
Work Location
Please list any other work related information you think would be helpful to us in considering you for employment, such as:
Specialized training, certifications, recent continuing education courses, additional work experience, etc
Other Information
References: (please list three individuals with whom you have worked who were in a position to evaluate your performance)
Name
Position
Address
Telephone
Name
Position
Address
Telephone
Name
Position
Address
Telephone
Additional Information
Page 2 of 5
Work Experience
Facility/Employer Name:
Name of Immediate Supervisor
Company Address
City, State Zip
Dates Employed
From
To
Position Title
Telephone No.
Pay Rate
May we Contact?
No
Yes If no, Why?
Number of Beds in Unit
In Hospital
Reason for Leaving
If this was a travel assignment, Name of Agency
Are your Employment Records listed under another name?
No
Yes If Yes, What Name?
Charge Experience?
No
Yes
How Often?
Facility/Employer Name:
Name of Immediate Supervisor
Company Address
City, State Zip
Dates Employed
From
To
Position Title
Telephone No.
Pay Rate
May we Contact?
No
Yes
If no, Why?
Number of Beds in Unit
In Hospital
Reason for Leaving
If this was a travel assignment, Name of Agency
Are your Employment Records listed under another name?
No
Yes
If Yes, What Name?
Charge Experience?
No
Yes
How Often?
Facility/Employer Name:
Name of Immediate Supervisor
Company Address
City, State Zip
Dates Employed
From
To
Position Title
Telephone No.
Pay Rate
May we Contact?
No
Yes
If no, Why?
Number of Beds in Unit
In Hospital
Reason for Leaving
If this was a travel assignment, Name of Agency
Are your Employment Records listed under another name?
No
Yes
If Yes, What Name?
Charge Experience?
No
Yes
How Often?
Page 3 of 5
Professional References
(To be completed by the applicant)
Attention
Position Held
Facility
Address
Dates Employed: From
To
Telephone
The individual named below has applied for a position as
and has provided your name as a reference
As we place great importance on the thorough screening of all our applicants, we would appreciate a prompt and thoughtful response.
Thank you in advance
Branch Leader
To be completed by the
Applicant
Applicant Release
Last Name
First Name
Middle In
Maiden
Social Security Number
I hereby release from all liability, the company or person completing this form, and authorize them to release all information regarding my employment with them. I
understand that this information may be released to clients of Our Company and other requesting third parties on a need-to know basis. I also release Our
Company of all liability for any damages from the disclosure of this information.
Applicant Signature
Date
(To be completed by the employer)
Applicant Professional References
Please confirm Applicants employment: From
To
Please comment on the applicants attributes, using the following the scale.
4 = Excellent 3 = Good 2 = Fair 1 = Poor N/A = Not Applicable
Quality of Work
Knowledge and Skills
Reliability and Attendance
Professional Dress and Grooming :
Flexibility and Adaptability
Clinical Competence
Supervisory Ability and Capacity
Cooperation
Please indicate any special consideration necessary when giving assignments to this individual.
Please indicate specialty areas in which the applicant has had experience at your facility:
Is Applicant eligible for rehire?
Additional Comments
YES
NO
If no, Why not?
Name (Please Print)
Signature Position/Title
Date
Page 4 of 5
NurseStaffing™ is an Equal Opportunity Employer
APPLICANT ACKNOWLEDGEMENT:
I certify
that the information in this application is accurate, current and complete. I understand that misstatements-
statements or omissions may result in disqualification from further consideration or termination of employment.
I authorize
NurseStaffing™ to investigate my employment history, credentials and to obtain any relevant information (including
a criminal background check) needed to make an employment decision. I authorize NurseStaffing™ to disclose this application
along with any information about me obtained through reference checks or during the course of the interview process for state,
federal, contractual or accreditation audit purposes. I also authorize NurseStaffing™ to disclose any of my performance
appraisals, disciplinary records or skills tests for the same purposes as above. I release NurseStaffing™ and any individual or
entity providing information to NurseStaffing™ from all liability for any damages from the disclosure of this information.
I also understand and agree that:
(place initials in boxes below)
Passing a medical examination and/or participating in a post-conditional offer medical screening may be
required. If medical restrictions cannot be reasonably accommodated, I may not be hired, or if hired,
employment may be terminated.
Subject to applicable state laws, the Company reserves the right to conduct drug screening and testing for
reasonable suspicion at any time during employment and as a pre-employment requirement. Any violation of
this policy shall result in an applicant not being hired or an adverse employment action up to and including
immediate termination. NurseStaffing™ has the right to change this policy at any time as it requires.
I understand and agree
that nothing contained in this employment application or in granting of an interview creates an
employment contract between NurseStaffing™ and myself for either employment or for the providing of any benefit. No
promises regarding employment have been made to me. If an employment relationship is established, I understand that my
employment will be terminable "at will", that I will have the right to terminate my employment at any time, and that
NurseStaffing™ will retain a similar right to terminate my employment at any time.
I understand
that should I become employed by NurseStaffing™, my work assignments, schedules and/or work locations are
subject to change according to the needs of the business and the clients of NurseStaffing™.
Applicant's Signature:
Date:
