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Profile Submission Form:

All questions with an * must be completed in order to submit application.

*First Name:





Middle Initial:








*Last Name:


















Contact Information:









*Current Phone Number (With Area Code):





Best time of day to reach you:





Mobile Phone Number (With Area Code):





Best time of day to reach you:





Work Phone Number (With Area Code):





*Street Address:




*City:
*State:




*Email:




*Date available for employment (MM/DD/YYYY):

















Nursing Experience (You can check more than one specialty):
Med/Surg
 PICU
 Post Partum
 NICU
 SDS
 ACU
OR/Rec ICU/CCU Burn ICU CVICU Endo/GI CRNA
ER Psych Tele/DOU Cardiac Cath Neuro Stepdown
Oncology Rehab MICU PACU Neuro ICU Ob/Gyn
Pediatrics L&D SICU Mom/Baby PCU Transplant
Quality Assurance
 Utilization Review
 Cardiac Rehab
 Home Health
 Geriatrics
 Dialysis
Infection Control
 Hyperbaric/Bariatric
 Hospice/LTC
 IV Therapy
 Cardiology
 Endoscopy
Pain Management
 Case Management
 Wound Care
 Orthopedics
 Radiology
 Other
If other, please give details:














Nursing Management Experience:
Charge Nurse:
 What Clinical Area: Years of Experience:
Head Nurse:
 What Clinical Area: Years of Experience:
Department Mgr:
 What Clinical Area: Years of Experience:


Ancillary Positions (Please check one):
LPN/LVN Surgical Tech MRI/CT Tech





PT/OT Pharmacist Other







Recent Nursing Graduates:
When did you graduate?
Are you working now?
If so, what clinical area are you working in?
Any special training in school/what area?
Where did you receive your degree?






Type of Nurse:


RN
 LPN/LVN   NP





Education:


Associate Degree - Nursing: School:
Bachelor of Science - Nursing: School:
Master of Science - Nursing: School:

Other Degrees/Schools:









Status:





*Country of Birth:
*Citizenship:
*Do you have US Resident/ Alien Status? Yes No

*Do you have your CGFNS Certificate?
(Commission on Graduates of Foreign Nursing Schools)		 Yes No

If no when do you plan to sit for exam (MM/DD/YYYY) - if applicable:
*Do you have your NCLEX Certificate? Yes No

If no, when do you plan to sit for exam (MM/DD/YYYY):







Language certification (If you studied nursing in English then this is not a requirement)
Did you take the Test of English as a Second Language (TOEFL) exam? Yes No Test Score:
Did you take the MELAB exam? Yes
 No
 Test Score:
Did you take the IELTS exam? Yes No Test Score:







License Information





Nursing License #
Licensing State (or Country)
Has your license ever been suspended or revoked? Yes No

Have you ever been convicted of a misdemeanor or felony? Yes No

Other Licenses:






Interested in (please check all that apply):
13-week 26 week/6 mo's 9 months 12 months Permanent





Travel Positions



Are you a traveler, or willing to consider travel positions?
 Yes
 No
In what states would you like to consider working?
Please list specific cities, or other states, if desired
Are you presently working for a Traveling Nurse Agency: Yes No
If yes, with which agency are you currently working?
What agencies have you worked for in the past (if any)?
What did you like about them?
What did you dislike about them?
What would be your preferred start date?
Are you willing to float?
 Yes No
If so, in what areas can you float?
Are your license, certifications, immunizations, and Health Statement up to date?
 Yes    No
What is/are your area of specialty/specialties?
Have you ever been credentialed in more than one area of practice?  Yes No
If so which ones?
Have you ever abandoned/quit a contract?
 Yes No
If yes, please explain the circumstances:
Have you ever been listed as DNR (do not return)?
 Yes No
If yes, please explain the circumstances:
Do you have 12 or more months of full-time clinical experience totaling 2,080 hours or more in the last 3 years?
 Yes
 No
What would you like to obtain from your next assignment?
Please list data systems/clinical equipment you are familiar with:
Do you currently have daily access to the internet?
 Yes No
Please list any relevant credentials you have earned:
Please list the states in which you are licensed:
Rank by importance (1-lowest, 5-highest) the following:



Location of work

Pay rate

Company or facility

Schedule

Overtime work

Benefits




Permanent Positions






Are you willing to relocate for a permanent position?
Yes No



To what states would you consider relocating?
Please list specific cities, or other states, if desired:








Benefits & Compensation:






*Present Hourly Compensation/Salary in US Dollars:










Please List All Benefits (including any allowances and amounts):




















Resume: Please attach Resume or Curriculum Vitae, if you have it, to this application form.



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