Superior Medical Staffing Agency

Service, Above and Beyond
 
Placing Local Medical Professionals in local Facilities
 

Application Form

Please fill out the information as requested. This form is use to gather information about your work experience and to verify your credentials and to match your experience and skills with the needs of our clients.  On this form, we do not require high security information such as your driver’s license, nursing registration certificate, Tax File Number, certification, and other credentials for security precautions. With an offer of employment from Superior Medical Staffing Agency, we require paper copies of all your licenses such as nursing registration certificate and other certification credentials. A signed paper application is needed for employment.

Thank you, Superior Medical Staffing Agency

 
First Name Last Name  
 
Telephone No. (Home) Telephone No. (Cell) Email
Street Address City State Zip
       
Work Objective Date available to start
Profession Specialty
Years of Experience at your current profession.    
       
Would you like to travel ?

Yes          No  

   
If yes, Where ? (Besides your home  states)    
Is your professional license valid in which state(s)    
       
Certifications CPR    ACLS      PALS        BLS       Other  
Have you work at your current profession the last 12 months ? Yes          No      
Are you employed now? Yes          No      
Do you have management experience? Yes          No   How many months?
Do you have supervisory experience? Yes          No   How many months?
Dou you have charge nurse experience? Yes          No   How many months?
Have you work as travel nurse? Yes          No   How many months?
       
Have you work on these units before? Medical/Surgical Yes   No How many months?
  Critical Care/Emergency Room Yes   No How many months?
  Nursery/Neonatal/Pediatric Yes   No How many months?
  Obstetrical Yes   No How many months?
  Operating Room Yes   No How many months?
  PACU Yes    No How many months?
  Psychiatric Yes    No How many months?
  Telemetry/PCU Yes    No How many months?
  Long Term Care Yes    No How many months?
  Homecare Yes    No How many months?
  Hospice Yes    No How many months?
  Doctors Office (Clinics) Yes    No How many months?
         
Shift Preference Days    
  Evenings    
  Nights    
  8 Hours Shift    
  12 Hour Shift    
         
Terms of Assignments Daily    
  Prn (On Call)    
  3 Months    
  6 Months    
  Permanent Placement    
Education (College) School Location  (State) Degree Did you graduate?  Yes   No 
Education (Vocational) School Location  (State) Degree Did you graduate?   Yes    No
Education (High School) School Location  (State) Degree Did you graduate?   Yes    No
         
Background        
     
Has your professional license or certification ever been investigated or suspended?  Yes     No   
Have you ever been convicted of a crime other than a minor traffic violation?  Yes     No   
Have you ever been named as a defendant in a professional liability action?  Yes     No   
Can you submit verification of your legal right to work in the United States?  Yes     No   
If you will be employed on a visa, please specify the type of visa.  
         
Person to notify just in case of emergency Relationship Telephone Alternate Phone.  
 
         
Employment History ( May we contact your present employer? )   Yes   No    
         
 Employer (Most Current) Department Dates (From) Dates (To) Comments
         
 Employer Department Dates (From) Dates (To) Comments
 Employer Department Dates (From) Dates (To) Comments
         
         
This is not an offer of employment, but we will contact you upon receiving your electronic data. We will match your experience with our clients needs and we will call you within 24-72 hours.