Employment Application

15849 N. 71st Street . Suite 100 - Scottsdale, AZ 85254 Toll Free: (877) 280-2600 - Fax: (877) 280-5200

Your Personal
Information

Today's date		Date Available
Name
Nickname		Social Security #
Current Mailing Address
City/State/Zipcode		Email
Current Phone		Cell Phone
Permanent Address
City/State/Zipcode
Permanent Phone		Are you currently a U.S. citizen? Yes No
In case of Emergency Contact		Current Phone
Relationship
Address
City/State/Zipcode
Were you referred by anyone? If so, who?

Personal
Credentials

Position (Job Class) Applying for:

LP/VN

CNA

CST

Tech

Allied

Other

Work Experience
/Skills

Please list the number of years you have experience in each area (minimum 1 year experience) and are clinically competent to work:

Burn	L & D	MICU	NICU
PACU	SICU	CCU	ENT
Rehab	Nursery	Dialysis	Geriatric
Pedi ICU	Med/Surg	Pediatrics	Telemetry
Psychiatry	Stepdown	Oncology	Neurology
Open Heart	Post Partum	Orthopedics	Detox/Drug Rehab
Mother/Baby	Recovery Room	Operating Room	Emergency Room
Other Specialty

Schedule
Preferences

Check the shift(s) you prefer below:

7am-3pm	7am- 7pm	3pm-11pm	7pm-7am
Other

Education

Education Vocational/Nursing School		City
State
Date Passed Boards/Certification		Degree Earned
College/University		City
State
Date Passed Boards/Certification		Degree Earned
College/University		City
State
Date Passed Boards/Certification		Degree Earned

License

License Type		License Certification Number
State		Expiration Date
License Type		License Certification Number
State		Expiration Date
License Type		License Certification Number
State		Expiration Date
License Type		License Certification Number
State		Expiration Date

	Exp.		Exp.		Exp.		Exp.
CPR		TNCC		TNS		ENPC
ACLS		PALS		NRP		NALS
Other

Current
Employment

Are you currently employed	Yes No
Hospital Name		City/State/Zip
Dates employed	Mo. / Yr. - Mo. / Yr.	Hospital Type	Teaching Non-Teaching
Reason for leaving		Position held	Hours per week?
Unit specialty		Average Patient Ratio
Hospital beds		Unit beds
Charge experience		Supervisor
Phone		Ext
Is this a travel assignment?	Yes No If yes, what company?	May we contact your current employer?	Yes No

Additional
Questions

Have you ever been convicted of a crime of pled guilty or no contest (nolo contendre) to any criminal charge?

Yes No
If yes, please indicate dates, conviction, and final outcome.
Date	Conviction	Outcome

Has your professional license (in any jurisdiction that you may have been licensed in) ever been investigated, suspended or revoked?

Yes No
If yes, please indicate dates, conviction, and final outcome.
Date	Conviction	Outcome

Do you have any malpractice or negligence suits pending?

Yes No
If yes, please indicate dates, conviction, and final outcome.
Date	Conviction	Outcome

Work Experience

List previous employers

Facility / Employer Name		Dates employed	Mo. / Yr. - Mo. / Yr.
Title		Unit Unit Bed Size
May we contact?	Yes No	Charge experience Yes No

Facility / Employer Name		Dates employed	Mo. / Yr. - Mo. / Yr.
Title		Unit Unit Bed Size
May we contact?	Yes No	Charge experience Yes No

Work Experience

List previous employers

Facility / Employer Name		Dates employed	Mo. / Yr. - Mo. / Yr.
Title		Unit Unit Bed Size
May we contact?	Yes No	Charge experience Yes No

Facility / Employer Name		Dates employed	Mo. / Yr. - Mo. / Yr.
Title		Unit Unit Bed Size
May we contact?	Yes No	Charge experience Yes No

Work Experience

List previous employers

Facility / Employer Name		Dates employed	Mo. / Yr. - Mo. / Yr.
Title		Unit Unit Bed Size
May we contact?	Yes No	Charge experience Yes No

Facility / Employer Name		Dates employed	Mo. / Yr. - Mo. / Yr.
Title		Unit Unit Bed Size
May we contact?	Yes No	Charge experience Yes No

Work Experience

List previous employers

Facility / Employer Name		Dates employed	Mo. / Yr. - Mo. / Yr.
Title		Unit Unit Bed Size
May we contact?	Yes No	Charge experience Yes No

Facility / Employer Name		Dates employed	Mo. / Yr. - Mo. / Yr.
Title		Unit Unit Bed Size
May we contact?	Yes No	Charge experience Yes No

Please
Sign Here

I authorize my past employers to provide information to StaffingMedical USA, Inc. about my job performance while in my employment with your facility. I also authorize StaffingMedical USA, Inc. to disclose this reference to any of its client institutions.
Please Sign Here:

Professional
Reference Check

Facility Name/Employer		City/State/Zipcode
Phone		Supervisor/Manager

Facility Name/Employer		City/State/Zipcode
Phone		Supervisor/Manager

Facility Name/Employer		City/State/Zipcode
Phone		Supervisor/Manager

Facility Name/Employer		City/State/Zipcode
Phone		Supervisor/Manager

Additional
Questions

How did you hear about Staffing Medical USA, Inc.?
Internet Staffing Medical Site Newspaper Trade Publication Job fair/Open House
Staffing Medical USA, Inc. employee: Name Work Location
Other

Please
Sign Here

The statements made in this application are true to the best of my knowledge. I understand that any falsification will be the basis for disqualification of employment or termination of service. I authorize StaffingMedical USA, Inc. to verify the information I have provided and to contact past employers and references concerning my ability, character and employment records. I release all such persons from liability for furnishing said information. I authorize StaffingMedical USA, Inc. and my employer to release a copy of this employment application and any medical information which may be relevant to my employment to their client facilities. By applying to StaffingMedical USA, Inc., I authorize release of this information to all other affiliates of the Company and I acknowledge and agree that they may contact me using facsimile or any other means. Nothing contained in this employment application, or in the granting of an interview, is intended to create an employment contract between StaffingMedical USA, Inc. and the applicant for either employment or for providing of any benefit. All offers of employment made conditional upon the applicant's proving employment authorization and identity in accordance with the Immigration Reform and Control Act of 1986.

Signature:

By printing my name here, I am acknowledging that everything in this form is true to the best of my knowledge and is acting as my electronic signature.

Date 02/06/2012