(Please complete event if attaching a resume)

Name

First Last

Maiden/Other

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

E-mail Address

Social Security Number

Date of Birth

Driver’s License

State

Select State

Expiration Date

Home Phone Number

Alternate Phone Number

Cell Phone Number

Preferred call time

Primary Emergency Contact Name

First Last

Primary Emergency Contact Phone Number

Secondary Emergency Contact Name

First Last

Secondary Emergency Contact Phone Number

Date Available

Shift Preferred

Day

Night

Type of position applying for (check all that applies)

Per Diem

8 Weeks

13 Weeks+

Permanent

Do you speak any languages other than English?

Yes

If yes, please list

How were you referred to us?

Advertising

Internet site

Friend / Associate

Other

Were you recruited by a Staff Member?

Yes

If yes, recruiter’s name

Have you done a Travel assignment before?

Yes

If yes, with which company(s)?

Are you able to perform the basic functions of the position for which you are applying without any restrictions?

Yes

If no, please explain

Position (Job Class) Applying for:

Date Available

Please use the field below to let us know your preferences in terms of Facility, Commute, Restrictions, Pay, etc.

Emergency Contact Information

We would like to have the names of two (2) contacts that we could call in the case of emergency. Please provide that information below for our files and reference.

Primary Contact:

First Last

Contact Number

Relationship:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Primary Contact:

First Last

Contact NUmber

Relationship:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Professional Credentials

Education

From:

To:

Degree Earned:

Education:

From:

To:

Degree Earned:

Specialty (Please list most current experience first)

Years of Experience

as of (Indicate Date)

Years of Experience

as of (Indicate Date

Professional Licenses (Please attach a copy of each including front and back copies)

1. CA Medical License Number

Expiry Date:

Certifications (Please attach a copy of each including front and back copies)

BLS / CPR

Expiry Date:

ACLS

Expiry Date:

PALS

Expiry Date:

NRP / NALS

Expiry Date:

MABB

Expiry Date:

CCRN

Expiry Date:

CNOR

Expiry Date:

TNCC

Expiry Date:

EKG Cert

Expiry Date:

CHEMO

Expiry Date:

Other:

Expiry Date:

Employment History

(Please list in order, most recent first and explain gaps in employment if any)

Date Employed: From:

To:

Business Phone:

Facility:

May We Contact?

Yes

Position Held

Specialty Unit:

May We Contact?

Traveler-Agency

Immediate Supervisor:

First Last

Pay / HR:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Reason for leaving:

Date Employed: From:

To:

Business Phone:

Facility:

May We Contact?

Yes

Position Held:

Specialty Unit:

May We Contact?

Traveler-Agency

Immediate Supervisor:

First Last

Pay / HR:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Reason for leaving:

Date Employed: From:

To:

Business Phone:

Facility:

May We Contact?

Yes

Position Held

Specialty Unit:

May We Contact?

Traveler-Agency

Immediate Supervisor:

First Last

Pay / HR:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Reason for leaving:

Date Employed: From:

To:

Business Phone:

Facility:

May We Contact?

Yes

May We Contact?

Traveler-Agency

Immediate Supervisor:

First Last

Pay / HR:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Reason for leaving:

Date Employed: From:

To:

Business Phone:

Facility:

May We Contact?

Yes

May We Contact?

Traveler-Agency

Immediate Supervisor:

First Last

Pay / HR:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Reason for leaving:

LEGAL QUESTIONNAIRE

Have you ever:

1. Been named as a defendant in a malpractice action?

Yes

If yes, when?

Who was your employer at that time?

First Last

2. Had a license or certification in any jurisdiction limited, suspended, revoked or voluntarily relinquished?

Yes

If yes, when?

In what state?

3. Been licensed or practiced professionally under a different name?

Yes

If yes, when?

In what state?

4. Are you eligible to work in the U.S.?

Yes

Alien ID number (if applicable)

5. Been denied a license?

Yes

If yes, what state?

When?

What reason?

6. Been convicted of not by misdemeanor, felony including traffic violations?

Yes

If yes, when?

In what state?

What country?

(This includes any offense where you were found guilty, plead guilty or plead nolo contendere (no contest). You may omit: a conviction of misdemeanor while under the age of 18, if the records were sealed. Any conviction specified in Health and Safety code which pertains to various marijuana offenses (a conviction will not necessarily disqualify you from consideration for employment).

7. Been arrested and are you out on bail on your own recognizance and still awaiting trial?

Yes

8. Been released or discharged from employment or resigned to avoid such release or discharged?

Yes

If yes, please provide dates and circumstances?

9. Had your driver's licensee suspended or revoked?

Yes

If yes, when?

Please explain why?

My signature certifies that all information contained within my application is correct and may be verified by Agency Staffing in compliance with State Law. It also acknowledges that I am aware that it is my responsibility to review and policy and procedure documents of each hospital/facility in which I work, prior to beginning my initial shift.

Applicant's Signature

Position

Date

I have reviewed the applicant's qualifications and skills that qualify for the position.

Evaluator's Signature

Date

Application For Employment

(Please complete event if attaching a resume)

Emergency Contact Information

Professional Credentials

Employment History

LEGAL QUESTIONNAIRE

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