Personal Information:

Name:

Current Phone:

Permanent Phone:

Jane Doe

xxx-xxx-xxxx

Other Names Used:

Cell Phone:

FAX:

none

xxx-xxx-xxxx

    

Date of Birth:

SSN:

E-mail Address:

xx-xx-xxxx

xxx-xx-xxxx

xxxxxxx@xxxxxxx.xxx

Citizenship:

 

Current Street Address:

159 Any Street, Apt 202

City, State/Prov, Zip/Postal:

Anytown, Anywhere, XXXXX

Permanent Address:

XX Any Street

City, State/Prov, Zip/Postal:

Anytown, Anywhere, XXXXX

Emergency Contact Name:

John Doe

Address:

Where Ever

City, State/Prov, Zip/Postal:

    

Phone:

 

Looking for:Travel Assignment               Available Immediately

Current Clinical Specialty:

1st: ER  

2nd: ICU

3rd:  Whatever    

Location Preference:

1st: CA 

2nd: Nevada

3rd:      

Shift Preference:

1st: 12 hour nights

2nd:  days    

3rd:      

Have you ever worked as a travel RN?                                                 Yes/No

Did you successfully complete your travel assignments?                      Yes/No  

 

Education:

School Name

City/ State (Prov.)/Country

Mo/Yr.Graduated

Diploma/Degree

Your School

wherever

xx/xxxx

RN

Post Graduate School

Wherever

xx/xxxx

ie: Masters etc

     

     

     

     

     

     

     

     

 

R.N. Licensure                                                                             Certifications

State/Prov.

Country

Number

Expiry

Name

Expiry

state

USA

xxxxxxxxxx

xx/xx/xxxx

CPR/BCLS

xx/xx

state

USA

xxxxxxxxxx

xx/xx/xxxx

ACLS

xx/xx

province

Canada

xxxxxxxxx

xx/xx/xxxx

NALS/NRP

xx/xx     

Country     

UK     

 xxxxxxxxxxx    

xx/xx/xxxx   

PALS

xx/xx     

     

     

     

     

CCRN

     

     

     

     

     

FHM

     

     

     

     

     

TNCC

 xx/xx    

     

     

     

     

MICN

xx/xx     

Experience:
 
Travel Assignments:

 

Employer:

Supervisor:

 

Location:

wherever

Telephone:

Job Title:

Travel Nurse

Travel Assignment:

Yes

Dates of Employment:

From:  xx/xx/xxxx

Rate of Pay:

Starting:       

 

To:      xx/xx/xxxx

 

Ending:        

Travel Company ::

Teaching Facility:

YES/NO

Type of Unit:

community ER

# of Beds in Hospital:

199

# of Beds in Unit:

27

 

Employer:

Wherever

Supervisor:

who ever

Location:

Telephone:

xxx-xxx-xxxx

Job Title:

Travel Assignment:

Yes

Dates of Employment:

From:  xx/xx/xxxx

Rate of Pay:

Starting:       

 

To:     xx/xxxxx

 

Ending:        

Reason for Leaving:

Or this can be Travel Company name see other sections to understand

Teaching Facility:

YES

Type of Unit:

Trauma Level 1 ER

# of Beds in Hospital:

600

# of Beds in Unit:

30

 

Employer:

Supervisor:

Location:

Telephone:

Job Title:

RN

Travel Assignment

Yes

Dates of Employment:

From: 

Rate of Pay:

Starting:       

 

To:     

 

Ending:        

Travel Company :

Teaching Facility:

NO

Type of Unit:

ER

# of Beds in Hospital:

258

# of Beds in Unit:

      16

 

Employer:

Supervisor:

Location:

Telephone:

Job Title:

RN

Travel Assignment

Yes

Dates of Employment:

From: 

Rate of Pay:

Starting:       

 

To:     

 

Ending:        

Travel Company :

Teaching Facility:

NO

Type of Unit:

ER

# of Beds in Hospital:

200

# of Beds in Unit:

      16

 

Employer:

Supervisor:

Location:

Telephone:

Job Title:

RN

Travel Assignment

Yes

Dates of Employment:

From: 

Rate of Pay:

Starting:       

 

To:     

 

Ending:        

Travel Company :

Teaching Facility:

NO

Type of Unit:

# of Beds in Hospital:

250

# of Beds in Unit:

      23

  

Employer:

Supervisor:

Location:

Telephone:

Job Title:

Travel Assignment

  

Dates of Employment:

From:

Rate of Pay:

Starting: 

 

To:

 

Ending:    

Travel Company :

Teaching Facility:

No

Type of Unit:

ER

# of Beds in Hospital:

# of Beds in Unit:

22

       

Employer:

Supervisor:

Location:

Delray Beach, FL

Telephone:

Job Title:

RN

Travel Assignment

Yes

Dates of Employment:

From: 

Rate of Pay:

Starting:       

 

To:     

 

Ending:        

Travel Company :

Teaching Facility:

  

Type of Unit:

# of Beds in Hospital:

# of Beds in Unit:

     

 

Employer:

Supervisor:

Location:

Telephone:

Job Title:

Travel Assignment:

 

Dates of Employment:

From: 

Rate of Pay:

Starting:       

 

To:     

 

Ending:        

Travel Company :

Teaching Facility:

  

Type of Unit:

# of Beds in Hospital:

# of Beds in Unit:

 

 

Employer:

Supervisor:

     

Location:

Telephone:

Job Title:

Travel Assignment:

  

Dates of Employment:

From: 

Rate of Pay:

Starting:       

 

To:     

 

Ending:        

Travel Company :

Teaching Facility:

 

Type of Unit:

# of Beds in Hospital:

# of Beds in Unit:

 

Employer:

Supervisor:

Location:

Telephone:

Job Title:

Travel Assignment:

Yes

Dates of Employment:

From: 

Rate of Pay:

Starting:       

 

To:     

 

Ending:        

Reason for Leaving:

Teaching Facility:

 

Type of Unit:

# of Beds in Hospital:

# of Beds in Unit:

 

Summary of Clinical Experience:

 

 

Clinical Area

Years of Experience

ER

ICU

OR     

     

 Telemetry    

     

 Whatever area     

     

 

Criminal Record:

An applicant for employment with a sealed record on file with the Commissioner of Probation may answer “no record” with respect to any inquiry below relative to prior arrests, criminal court appearances, or convictions. An applicant for employment may answer “no” if his or her criminal record consists only of one or more of the following: (1) an arrest, detention or disposition regarding any violation of law in which no conviction resulted; or (2) a case of delinquency or a child in need of services, which does not result in a complaint transferred to the superior court for criminal prosecution.

 

1. Have you ever been convicted of a felony?       NO

   If so, list nature of offence, dates of conviction and dates of any incarceration associated

  therewith:

     

 

2.  Have you ever been convicted of a misdemeanor?    NO

   If so, please list the nature of the offence, date of conviction and dates of incarceration associated therewith. You may answer “no” if your criminal record consists of one or more of the following: (1) Any misdemeanor conviction where the date of conviction or completion of incarceration occurred 5 or more years before the date of this application, unless you were convicted of another offence during the past 5 years; or (2) A first conviction of drunkenness, simple assault, speeding, minor traffic offences, disturbance of the peace or affray.

     

 

Notice to Applicant:

The following section contains important information regarding your legal rights and contains important certifications and releases of liability. Please read it carefully before signing.

 

Upon termination, I authorize my agency to provide information to my prospective employers regarding my employment history and performance and hereby release my agency and any person employed by it or associated with it from all liability in connection with the provision of such information.

 

I hereby certify that the information contained in this Application is true, complete and correct. I understand and agree that falsifications, misrepresentations or omissions may constitute grounds for dismissal. I grant my agency access to any listed contact to verify facts as presented herein or to gain reference information. I understand that I will be required to successfully complete a physical examination prior to commencing employment and that the examination will include a urine test that will check for the presence of non-prescription or non-prescribed drugs or prohibited controlled substances or alcohol.

 

By signing below, I acknowledge that I have read, understood and voluntarily agree to the above.

(Please print and sign/date the application form.)

 

 

Date:                ______________________________________________________

 

 

Signature:         ______________________________________________________


Additional Experience:

Non Travel Work or perhaps non nursing work or can be deleted

Employer:

Supervisor:

Location:

Telephone:

Job Title:

Travel Assignment

  

Dates of Employment:

From: 

Rate of Pay:

Starting:       

 

To:    

 

Ending:  

Reason for Leaving:

Teaching Facility:

  

Type of Unit:

# of Beds in Hospital:

# of Beds in Unit:

 

Employer:

Supervisor:

Location:

Telephone:

     

Job Title:

Travel Assignment:

Dates of Employment:

From:

Rate of Pay:

Starting:       

 

To:     

 

Ending:  

Reason for Leaving:

Teaching Facility:

  

Type of Unit:

# of Beds in Hospital:

# of Beds in Unit:

 

Employer:

Supervisor:

Location:

Telephone:

     

Job Title:

Travel Assignment:

 

Dates of Employment:

From: 

Rate of Pay:

Starting:       

 

To:     

 

Ending:  

Reason for Leaving:

Teaching Facility:

  

Type of Unit:

# of Beds in Hospital:

# of Beds in Unit:

 

Employer:

Supervisor:

     

Location:

Telephone:

     

Job Title:

Travel Assignment:

  

Dates of Employment:

From: 

Rate of Pay:

Starting:       

 

To:     

 

Ending:  

Reason for Leaving:

Teaching Facility:

Type of Unit:

# of Beds in Hospital:

# of Beds in Unit:

 

Employer:

see resume for previous positions

Supervisor:

     

Location:

     

Telephone:

     

Job Title:

     

Travel:  

Permanent: 

Dates of Employment:

From:       

Rate of Pay:

Starting:       

 

To:           

 

Ending:        

Reason for Leaving:

     

Teaching Facility:

Yes            No

Type of Unit:

     

# of Beds in Hospital:

     

# of Beds in Unit: