Apply Now!

At Quality Medical Staffing, we strive to make our application process, convenient, efficient, and as simple as possible to save you time. No matter when you plan to travel, submitting your application now will allow us to keep you posted as new assignments become available. Keep in mind that submitting your application to us now does not in any way obligate you to accept an assignment from us. It only allows us to offer you assignments and opportunities based on the criteria that you set.

 
I . General Information:
First Name:
Middle Name:
Maiden Name:
Last Name:
Address:
City:
State:
ZIP:
E-Mail Address:
How Did You Hear About Us?
Home Phone:
Cell Phone:
Other Phone:
Best Time to Contact:
   
Emergency Contact (Name):
Relationship:
Phone:
 
 
II . Employment Profile:
Please check Yes or No for the following questions: YES NO
1. Can you provide proof of eligibility to work in the United States?
2. Have you ever been convicted of a crime that would prevent employment at a health care facility? If yes, please provide a detailed explanation in the Notes section below.
3. Have you ever had a license or certification investigated, revoked, or suspended? If yes, please provide a detailed explanation in the Notes section below..
4. Do you have at least one year of current experience on a hosptial floor?
5. Are you willing to submit to a criminal background check?
6. Are you willing to submit to a drug screen?
7. Do you have any limitations that would restrict you from performing essential functions in the position for which you are applying? If yes, please provide a detailed explanation in the Notes section below.
8. Are your driving privileges suspended or revoked in any state? If yes, please provide a detailed explanation in the Notes section below.
9. Can you provide proof of auto insurance for rental car usage?
Notes relating to responses above:
 
III. Education:
School / University Location Month / Year Graduated Degree / Diploma Awarded
 
IV. Expertise/Experience:
Unit / Specialty Years of Experience Equipment / Procedures
       
V. Work History:
List below all permanent positions (full-time & part-time), local agency, and travel assignments.
Facility:
Location:
Dates Employed:
Unit:
Number of Beds:
Supervisor:
Phone:
Reason for Leaving:
Employment Type (Full Time, Part Time, Travel/Temp, etc)
   
       
Facility:
Location:
Dates Employed:
Unit:
Number of Beds:
Supervisor:
Phone:
Reason for Leaving:
Employment Type (Full Time, Part Time, Travel/Temp, etc)
   
       
Facility:
Location:
Dates Employed:
Unit:
Number of Beds:
Supervisor:
Phone:
Reason for Leaving:
Employment Type (Full Time, Part Time, Travel/Temp, etc)
   
       
Facility:
Location:
Dates Employed:
Unit:
Number of Beds:
Supervisor:
Phone:
Reason for Leaving:
Employment Type (Full Time, Part Time, Travel/Temp, etc)
   
       
VI. Professional References:
Name: Title: Facility: Contact Number:
       
VII. Licensure:
State: License Number: Issue Date: Expiration Date:
       
VIII. Certifications:
Certification: Expiration Date: Certification: Expiration Date:
BLS Other:
OCN Other:
ACLS Other:
Critical Care Course Other:
PALS Other:
Trauma Course    
NALS / NRP    
Chemotherapy    
CNOR    
CEN    
CCRN    
 
IX. Application Certification:
I certify that all statements made in this application are true to the best of my knowledge. I understand that any falsification or misleading information given in my application may result in the termination of my employment with Quality Medical Staffing. Further, I understand that nothing contained in this application is intended to create an employment contract, either verbal or written, with Quality Medical Staffing or its clients. I understand that in the event of my employment, it is "at will".
   
Applicant's Full Name:
Type Your Initials:
Date:

   



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