|
*Print
Full Name:
*Street/Apt
#:
*City:
County:
*State:
*Zip:
*Primary
Phone #:
Secondary Phone #:
Email Address:*Social
Security #:
*D.O.B.
*Nursing License or Certificate #, & Expiration Date:
*Position
Applying For: (must
select one)
Have you ever worked for AMS?
Referred By:
Are you currently oriented at any hospitals through another agency?
If yes, which hospitals?
Healthcare
Experience-------------------------------------------------------------------------------------------------------------------------
*1.Name
of Last / Current Employer:
*Address:(street,
city, State, Zip)
*Phone
#:
End Pay:*Your
Title:
*Units
Worked: CCU/ICU
PCU/Tele/Step Down
ER/ED
Med/Surg
Long
Term Care Other
*Supervisor
Name / Title:*Start
Date:*End
Date:
Reason for Leaving:
*2.Name
of Previous Employer:
*Address:(street,
city, State, Zip)
*Phone
#:*Your
Title:
*Units
Worked:CCU/ICU
PCU/Tele/Step Down
ER/ED
Med/Surg
Long
Term Care Other
*Supervisor
Name / Title:
*Start Date:
*End
Date:
Reason for Leaving:
*What
counties are you willing to staff?
Assignment
Preference-------------------------------------------------------------------------------------------------------------------------
Full TimePart
TimePer
DiemContractDaysEveningsOvernight
Education--------------------------------------------------------------------------------------------------------------------------------------------
*Institution:
*Location:
*Degree:
*Date
Obtained:
Physical
Condition------------------------------------------------------------------------------------------------------------------------------
Do you have a physical condition or handicap that will limit your ability to
perform the job applied for?
If Yes, Please Explain:
Employment
Questionnaire-------------------------------------------------------------------------------------------
*1.
Do you have a Criminal Record?
(must select one)
If Yes, Please Explain:
*2.
Is your Nursing License currently in good and active standing with the State of
residence?
If No, Please Explain:
*3.
How long have you resided in your current State of residence?*Years *Months
If less than 5 years, have you recently completed a Background Screening that
included fingerprinting?
*
I hereby certify, under penalty of immediate dismissal, that this application
for employment has been completed fully and correctly. I understand that
inquires will be made to my former employers or their agents including
information regarding my employment dates, and position. My
permission is hereby granted to make such inquiries. Advantage Medical Staffing
Inc. is required by the State Department of Professional Regulations to conduct
background checks on all of its healthcare workers. Advantage Medical Staffing
Inc. is a drug-free workplace. Therefore, I agree to submit to a drug screen, as
well as a verification of my professional nursing license or certificate.
*
I understand that my status with Advantage Medical Staffing will be terminated
if the background check or drug screen are returned with disqualifying offenses.
*
I understand that this information will be maintained as confidential and is nondiscriminatory per company policy in relation to race,
creed, religion, sexual orientation, age or handicap.
*
I have read and understand the Terms and Conditions for this website.
*Signature
(Please Type Full Name):
Additional Comments:
|
