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Supplemental StaffingRN Recruiting
FAQs: Supplemental StaffingFAQs: RN Recruiting

Supplemental Staffing Application:
To APPLY ONLINE, Complete the form below:

*Required Fields

First Name*:

Middle Initial:

Last Name*:
Current Address*:
Street:
City:
State:
Zip:
Home Phone*:
Work Phone:
Permanent Address*:
Street:
City:
State:
Zip:
Email Address*:
Confirm Email Address*:
Professional Discipline*:
Specialty:
Social Security Number*:
How Did You Learn About Us?*:
Nursing Licensure        
State License # State License #
1)
5)
2)
6)
3)
7)
4)
8)
Has your professional license or certification ever been investigated or suspended?
If yes, please explain:
Have you ever been convicted of a crime other than a minor traffic violation?
If yes, please explain:
Have you ever been named as a defendant in a professional liability action?
Can you submit verification of your legal right to work in the U.S.?
If you will be employed on a visa, please specify type of work visa:
Clinical Experience
Area
From: (mm/yyyy)
To: (mm/yyyy)
Area
From: (mm/yyyy)
To: (mm/yyyy)

Burns

Neurology
CCU
Occupational
CVTICU
Oncology
Dialysis
Operating Room
ER Trauma1
Neonatal/ICU
ER Level 2
Pediatrics
ER Triage
Peds ICU
GYN
Psychiatry
L&D
Post Anesthetic
Medical-ICU
Rehabilitation
Elemetry
Surgical ICU
Education Name & Location of School
Month / Year Graduated
Diplomas, Degrees Received
College
Graduate School
Other School
(if applicable)
Person to notify in case of emergency:
Name:
Relationship:
Street Address:
City:
State:
Zip:
Phone:

Employment Profile

Please Indicate all of your employment for the past ten years, beginning with the most recent employer.

Are you employed now? Yes No     If so, may we contact your present employer? Yes No

1.Facility/Employer:
Dept.
Street Address:
City:
State:
Zip:
Dates employed:
From: To:
Reason for leaving:
Position Held:
Specialty:
Supervisor's Name and Title:
Phone:
Other Supervisor?:
Phone:
2.Facility/Employer:
Dept.
Street Address:
City:
State:
Zip:
Dates employed:
From: To:
Reason for leaving:
Position Held:
Specialty:
Supervisor's Name and Title:
Phone:
Other Supervisor?:
Phone:
3.Facility/Employer:
Dept.
Street Address:
City:
State:
Zip:
Dates employed:
From: To:
Reason for leaving:
Position Held:
Specialty:
Supervisor's Name and Title:
Phone:
Other Supervisor?:
Phone:
4.Facility/Employer:
Dept.
Street Address:
City:
State:
Zip:
Dates employed:
From: To:
Reason for leaving:
Position Held:
Specialty:
Supervisor's Name and Title:
Phone:
Other Supervisor?:
Phone:
5.Facility/Employer:
Dept.
Street Address:
City:
State:
Zip:
Dates employed:
From: To:
Reason for leaving:
Position Held:
Specialty:
Supervisor's Name and Title:
Phone:
Other Supervisor?:
Phone:
6.Facility/Employer:
Dept.
Street Address:
City:
State:
Zip:
Dates employed:
From: To:
Reason for leaving:
Position Held:
Specialty:
Supervisor's Name and Title:
Phone:
Other Supervisor?:
Phone:

Please explain all gaps in employement history.
Have you ever been fired, asked to resign, suspended or received written discipline? Yes No


Professional References
Appropriate references are department heads, supervisors, charge nurses, nurse managers, and/or registered nurse with whom you have worked in the past two years. Give the full name and title.

1. Name:
Title:
Home Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Hospital in which you worked with this reference:
Facility City, State:

2. Name:
Title:
Home Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Hospital in which you worked with this reference:
Facility City, State:

3. Name:
Title:
Home Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Hospital in which you worked with this reference:
Facility City, State:
 
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