* Required
LICENSING / CERTIFICATIONS / CREDENTIALS
RN License #
Originating Body/State:
RN License #
Expiry Date:
American Heart Association BLS (Only AHA Acceptable)
*
Originating Body/State:
American Heart Association BLS (Only AHA Acceptable)
*
Expiry Date:
AHA - ACLS
Originating Body/State:
AHA - ACLS
Expiry Date:
AHA - PALS
Originating Body/State:
AHA - PALS
Expiry Date:
Am. Academy of Pediatrics - NRP
Originating Body/State:
Am. Academy of Pediatrics - NRP
Expiry Date:
TNCC
Originating Body/State:
TNCC
Expiry Date:
CCRN
Originating Body/State:
CNOR
Originating Body/State:
Allied Licensed Health Professionals:
Originating Body/State:
Allied Licensed Health Professionals:
Expiry Date:
MEDICAL RELATED CREDENTIALS: Current
TB/PPD (Positive TB/PPD skin test requires a current <1yr clear
chest X-ray report )
Lab / MD / Clinic Name:
Current TB/PPD (Positive TB/PPD skin test requires a current <1yr
clear chest X-ray report )
Expiry Date:
TB Screening Questionnaire
Lab / MD / Clinic Name:
TB Screening Questionnaire
Expiry Date:
Chest X-Ray Report
Lab / MD / Clinic Name:
Chest X-Ray Report
Expiry Date:
Rubella Numerical Titer
Lab / MD / Clinic Name:
Rubella Numerical Titer
Expiry Date:
Rubeola Numerical Titer
Lab / MD / Clinic Name:
Rubeola Numerical Titer
Expiry Date:
MMR Vaccine / Mumps Titer
Lab / MD / Clinic Name:
MMR Vaccine / Mumps Titer
Expiry Date:
M.D. Work Clearance < 9months
Lab / MD / Clinic Name:
M.D. Work Clearance < 9months
Expiry Date:
Enter others here:
Lab / MD / Clinic Name:
Enter others here
Expiry Date:
APPLICATION DATA:
It is
important that you fully and accurately complete this form yourself and
indicate the position(s)
for which you wish to be considered. The following must be filled out
completely for your application to
be considered.
Full Name:
*
Have you ever used another name?:
Contact Phone #
*
Have you ever used another name?:
Message Phone #:
Contact Email
*
Date Of Birth
*
Social Security #:
Have you ever used another Social Security Number?
*
YES
NO
Driver’s License
*
State Issued:
*
Present Address:
No. Street City State Zip:
Mailing Address:
No. Street City State Zip:
EMPLOYMENT APPLIED FOR:
CHOOSE BELOW:
TRAVEL NURSE
PER-DIEM/LOCAL RN
ALLIED TRAVELER
ALLIED PER-DIEM/LOCAL
REFERENCES:
Referral Source:
Search Engine?:
MANAGEMENT / COLLEAGUE REFERENCES:
MANAGER #1
LICENSED MANAGER /
COLLEAGUE FULL NAME EMAIL ADDRESS FAX # FACILITY NAME:
SUPERVISOR #1
LICENSED MANAGER / COLLEAGUE
FULL NAME EMAIL ADDRESS FAX # FACILITY NAME:
COLLEAGUE #1
LICENSED MANAGER / COLLEAGUE
FULL NAME EMAIL ADDRESS FAX # FACILITY NAME:
COLLEAGUE #2
LICENSED MANAGER / COLLEAGUE
FULL NAME EMAIL ADDRESS FAX # FACILITY NAME:
ACADEMIC HISTORY:
High School
Name and Address, Degree
Obtained, Date Graduated:
College/University
Name and Address, Degree
Obtained, Date Graduated:
College/University
Name and Address, Degree
Obtained, Date Graduated:
Trade or Tech School
Name and Address, Degree
Obtained, Date Graduated:
EMPLOYMENT HISTORY:
Current
Travel Nurse Company or Per-diem Agency Name:
Last shift date completed with this agency:
Check-stub verifiable wage rate at this agency:
List below all present and past
permanent employment, starting with your most recent employer:
Are You Employed Now?:
YES
NO
May we contact your present employer?:
YES
NO
NAME OF EMPLOYER #1:
Address
No. Street, City; State,
Zip:
Telephone:
Your Supervisor’s Name:
Type of Facility - Acute / Subacute:
Employment Ended Voluntarily?:
YES
NO
Your position and duties:
Date of Employment
mo/yr - mo/yr:
Earnings (Mandatory)
Starting - Ending Salary:
Exact Reason for Leaving:
NAME OF EMPLOYER #2:
Address
No. Street, City; State,
Zip:
Telephone:
Your Supervisor’s Name:
Type of Facility - Acute / Subacute:
Employment Ended Voluntarily?:
YES
NO
Your position and duties:
Date of Employment
mo/yr - mo/yr:
Earnings (Mandatory)
Starting - Ending Salary:
Exact Reason for Leaving:
NAME OF EMPLOYER #3:
Address
No. Street, City; State,
Zip:
Telephone:
Your Supervisor’s Name:
Type of Facility - Acute / Subacute:
Employment Ended Voluntarily?:
YES
NO
Your position and duties:
Date of Employment
mo/yr - mo/yr:
Earnings (Mandatory)
Starting - Ending Salary:
Exact Reason for Leaving:
DISCLAIMER INFORMATION:
The Company does not discriminate on the basis of any legal-protected
category and considers applicants
for all positions without regard to race, color, religion, creed,
national origin, age, disability, veteran
status, gender and sexual orientation.
Please check the appropriate box for each question. If you answer "YES"
to any of the following,
please use the box provided to describe details.
You must fully and accurately complete the Application for employment.
Incomplete applications will not
be considered. SOUTHWEST SWAT NURSES may use the information given in
the application to verify the applicant's
previous employment.
A)
Were/are you a member of the U.S. Armed Forces?
YES
NO
Branch of Service?
*
B) If you are under 18 years of age, can you provide required proof of
your eligibility?
*
YES
NO
C) ADA - Can you perform all job-related functions with or without
reasonable accommodations?
*
YES
NO
D) Are you currently authorized to work in the United States for any
employer?
*
YES
NO
E) Have you ever been convicted of a crime other than a minor traffic
offense (including Military Service)?
* <
YES
NO
If yes, please explain:
F) The agency you are applying to conducts criminal record checks.
Failure to divulge complete information will
disqualify you from employment. However, conviction will not
necessarily disqualify an applicant from employment.
*
Check
to acknowledge this
G) Are you charged with an unresolved criminal charge? (are you charged
with a crime that has not yet resulted in a plea of guilty, court
trial, deferred adjudication or dropping of the charge?) If yes,
explain fully
*
YES
NO
If yes, please explain:
H) To your knowledge, are you presently the subject of any
investigation or procedure by any agency, registry, or healthcare
provider?
*
YES
NO
If yes, please explain:
I) Are you now, or have you ever been a defendant in any litigation
alleging neglect or impropriety relating to your performance in the
field of healthcare?
*
YES
NO
If yes, please explain:
J) Has any agency, registry, or healthcare facility within the past
five (5) years, cancelled any contract with you as a healthcare
professional for any reason other than at your request?
*
YES
NO
If yes, please explain:
K) During the past ten (10) years, has any licence or certification of
yours been cancelled, revoked, or refused issue or renewal?
*
YES
NO
If yes, please explain:
SUBMISSION:
I acknowledge that SOUTHWEST SWAT NURSES has the right to deny this
application for any adverse information submitted or discovered in the
application.
I hereby attest that my answers appearing on this application are fully
true. I acknowledge that any material
information given in this application found to be incorrect or
incomplete, shall be grounds for immediate
termination at the sole discretion of SOUTHWEST SWAT NURSES. I give
SOUTHWEST SWAT NURSES the right to contact
my previous employers for verification purposes.
I authorize SOUTHWEST SWAT NURSES, to release any medical information
required for employment to their client
facilities. I understand that this information is scanned and posted on
a secured web-site that is accessible to
their client facilities and other affiliates of SOUTHWEST SWAT NURSES.
I understand that this application is not a contract of employment. I
also understand and agree that, if hired,
my employment would not be for a definite period and could be,
regardless of the date of payment of my wages and
salary, terminated at will, at any time without prior notice, with or
without cause.
In submitting this application for employment, I acknowledge that an
investigation may be made whereby information is
obtained regarding my character, previous employment, general
reputation, education, education background, and/or
criminal history.
My entered name below shall be considered a valid legal signature
according to the E-Sign Act of 2000.
E-signatures are considered equal to, and the same as, a manually
signed document.
To proceed, please click AGREE, then continue below:
*
AGREE
DON'T AGREE
Candidate's/Applicant's Full Legal Name:
*
Date:
*
