Med Staffers - We never stop working for you



All applicants selected for employment with Med Staffers must satisfactorily pass a pre-employment drug screen and criminal background check to be eligible for employment. Med Staffers is an Equal Opportunity and Affirmative Action Employer. Med Staffers only hires individuals who are authorized to work in the United States. This application is subject to the conditions set forth in the Certification and Agreement section on the last page. PLEASE COMPLETE APPLICATION IN FULL
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RN LPN CNA STNA HHA PT OT RT RAD Other

First Name:		Last Name:
Middle Initial:		Social Security #:
Current Address Line1:		Current Address Line2:
City:		State:
Zip Code:		County:
Work Phone:		Home Phone:
Cell Phone:		E-mail Address:
	Source of Referral:
	Walk-in		Med Staffers Referral:
	Past Med Staffers Experience		Job Service
	Newspaper		School Organization Referral
	Internet		Yellow Pages
	Other:

If you are working with Recruiter already please indicate name:

Have you ever been convicted of a felony or a misdemeanor, or have you ever plead no contest to any criminal charges? Yes No
Provide date, city, state and an explanation for all yes responses. Use additional space if necessary.

Criminal conviction is not an absolute bar to employment but will be considered in relation to specific job requirements.

Can you perform the functions of the job for which you are applying, either with or without a reasonable accommodation? Yes No

Do you have any relatives employed by Med Staffers? Yes No
If yes, Who/Relationship:

Work Availability:

Current Salary: $ Minimum Salary: $ Date of available work:

Full-time
Part-time
On-Call
Hours Available

Work Weekends: Yes No
Rotating Shifts: Yes No
Days
Evenings
Nights

Emergency Contact:

In case of an emergency, please contact:
Name: Phone: Address:

Education:

Have you graduated from High School or completed the GED equivalent? Yes No

List all degrees that you have received. List your highest degree first. Do NOT list degrees that you are currently working toward (see below). Additional space is available at the end of the application.

Major	Degree	School	Graduation Date

Are you currently enrolled? Yes No
Last year attended: Major:

Check last level of school completed:

Years completed:	Undergraduate:	Freshman	Sophomore	Junior	Senior
	Graduate:	1st year	2nd year	3rd year	4th year

Licensure/Registration/Certification:
List all professional licenses, registrations, and certifications. Additional space is available at the end of the application.

Lic/Reg/Cert Type	License Number	State	Expiration Date

Please indicate which of the following credentials you currently hold:

CPR:	Yes No -> Expiration Date:
BCLS:	Yes No -> Expiration Date:
ACLS:	Yes No -> Expiration Date:
NALS:	Yes No -> Expiration Date:
PALS:	Yes No -> Expiration Date:

Please indicate which of the following certification you currently hold:

CCRN:	Yes No -> Expiration Date:
CEN:	Yes No -> Expiration Date:
CHEM:	Yes No -> Expiration Date:
CRRN:	Yes No -> Expiration Date:
OCN:	Yes No -> Expiration Date:
CNOR:	Yes No -> Expiration Date:
Critical Care Course:	Yes No -> Expiration Date:

Do you have any pending restrictions and/or suspensions on your current professional license/registration that would restrain you from performing in this position? Yes No

Have you ever been refused professional licensure, or had a license / registration suspended or revoked? Yes No
If yes, please explain:

Employment History:
Start with your most recent employment, record of all employment and reasons for periods of unemployment. Additional space is available at the end of the application.

Company Name	Address	City	State	Zip Code	(Area Code) Phone

Type of Business	Supervisors Name, Title, and Phone Number	Date Employed	Date Left

Title and Duties:	Reason(s) for leaving:

If your employment record exists under another name, please specify:
Final Salary: $

Company Name	Address	City	State	Zip Code	(Area Code) Phone

Type of Business	Supervisors Name, Title, and Phone Number	Date Employed	Date Left

Title and Duties:	Reason(s) for leaving:

If your employment record exists under another name, please specify:
Final Salary: $

Company Name	Address	City	State	Zip Code	(Area Code) Phone

Type of Business	Supervisors Name, Title, and Phone Number	Date Employed	Date Left

Title and Duties:	Reason(s) for leaving:

If your employment record exists under another name, please specify:
Final Salary: $

Provide Three Work Related References:

Name	Occupation or Title	Firm Name and Address (Include City, State, and Zip)	(Area Code) Phone	Years Known

For Traveling Nurses Only

States Interested in Traveling to:

Hospitals Interested in Working at:

Additional information/comments:

CERTIFICATION AND AGREEMENT

I certify that the information I provided in this application is complete and accurate to the best of my knowledge. I understand that any misrepresentation or omission of facts in this application disqualifies me from further consideration, or, if I am employed, is sufficient cause for dismissal. I understand that any alteration of this application\'s content or form may be considered cause for disqualification and/or termination.

I authorize investigation of all statements contained in this application and understand that I may be required to provide verification (diploma, license, transcripts, type tests, etc.) of information contained in this application.

I authorize any and all persons, companies or agencies to release to Med Staffers any and all information they may have which is relevant to the application process. I also release all such parties from any liability that may result from furnishing information to Med Staffers.

I understand that to be considered as a formal applicant, the position for which I am applying must be specifically identified as open, and recruitment for the position going on at the time this application is received by the Human Resources Department.

I understand that, if I have not worked for Med Staffers for over one year, that I may be asked for additional references and employment information.

I understand that if I am employed with Med Staffers, my employment will be at-will. As such, it can be terminated by me or by Med Staffers with or without advance notice, at any time, and for any reason not prohibited by law. I agree that if I am employed by Med Staffers, I will review the information contained in Med Staffers\'s General Information Handbook.

I understand that any employment offer is contingent upon the following: ⁽¹⁾ producing documents establishing my eligibility to work in the United States; ⁽²⁾ satisfactorily passing the pre-employment drug screen, criminal background and reference checks; and ⁽³⁾ complying with Med Staffers\'s pre-employment application procedures.

I Agree
By checking "I Agree" and submitting this application to Med Staffers, I acknowledge that I have read the certification and agreement and agree to abide by its terms.

Med Staffers is an Equal Employment Opportunity / Affirmative Action Employer.