NURSES 911 LLC EMPLOYMENT APPLICATION
Contact Information
Date:
Classification: RN LPN ❏ OTHER ❏
How did you hear about Nurses 911 LLC?__________________________________
Have you ever applied with us before? Yes ❏ No ❏
First Name: _____________________MI: ______ Last Name: _________________________
Current Address: ______________________________________________________________
City: ____________________State: ______________________Zip Code:_________________
Current Phone: ________________Permanent Phone: __________________________
Cell Phone: ________________________E-mail: _______________________________
Permanent address: _______________________________________________________
City: ____________________State: __________________________Zip Code:_____________
Employment Status
Are you a U.S. Citizen? Yes ❏ No ❏
If not a U.S. Citizen, please indicate your immigration status: H1-B Visa❏ TN Visa❏ Alien❏
Social Security Number: _________________Drivers License #:____________State: ______
License
Original state of licensure: _________ Exp. Date: ________ License # _____________________
Additional active licenses held:
State: ______________ Exp. Date: ________ License # ________________________
State: ______________ Exp. Date: ________ License # ________________________
State: ______________ Exp. Date: ________ License # ________________________
Has your license ever been under restriction? Yes ❏ No ❏
If yes, explain: ________________________________________________________________
Have you ever been convicted of a crime other than minor traffic violation? Yes ❏ No ❏
Have you ever been named as a defendant in a malpractice claim? Yes ❏ No ❏
Has your professional license or certificate been investigated or suspended? Yes ❏ No ❏
Do you hold a professional license in any other name? Yes ❏ No ❏
If you answered YES to any of the above 4 questions, please attach a separate sheet with explanation including dates
and outcomes.
Certifications:
Certification Cert Number Expiration Date
_______________________________________________
_______________________________________________
_______________________________________________
Professional Organizations/Memberships:_________________________________
Bloodborne Pathogen/OSHA Education or Update Date: ____________________________
POSITION APPLYING FOR (PLEASE BE SPECIFIC) ____________________________________________
SOONEST AVAILABLE START DATE: ______________________________________________
Healthcare Staffing Employment Application
Employment History (please begin with most recent employment)
Facility/Agency:_______________________________________________________________
Address:_____________________________________________________________________
Begin date: _________________________End date: _________________________________
Position: ____________________________________Charge experience: Yes ❏ No ❏
Specialty/Unit: ________________ ____________________
Have you floated to other units? Yes ❏ No ❏ If so, please list: ________________________
Number of beds in facility: ____________________Teaching facility? Yes ❏ No ❏
Number of beds in unit: _________________Nurse/patient ratio: ______________________
Immediate supervisor: __________________Supervisor phone: _______________________
Reason for leaving: ___________________________________May we contact? Yes ❏ No ❏
Facility/Agency:_______________________________________________________________
Address:___________________ __________________________________________________
Begin date: _________________________End date: _________________________________
Position: ____________________________________Charge experience: Yes ❏ No ❏
Specialty/Unit: ________________ ____________________
Have you floated to other units? Yes ❏ No ❏ If so, please list: ________________________
Number of beds in facility: ____________________Teaching facility? Yes ❏ No ❏
Number of beds in unit: _________________Nurse/patient ratio: ______________________
Immediate supervisor: __________________Supervisor phone: _______________________
Reason for leaving _______________________________ May We Contact? Yes ❏ No ❏
Facility/Agency:_______________________________________________________________
Address:_____________________________________________________________________
Begin date: _________________________End date: _________________________________
Position: ____________________________________Charge experience: Yes ❏ No ❏
Specialty/Unit: ________________ ____________________
Have you floated to other units? Yes ❏ No ❏ If so, please list: ________________________
Number of beds in facility: ____________________Teaching facility? Yes ❏ No ❏
Number of beds in unit: _________________Nurse/patient ratio: ______________________
Immediate supervisor: __________________Supervisor phone: _______________________
Reason for leaving ___________________________________ May We Contact? Yes ❏ No ❏
Facility/Agency:_______________________________________________________________
Address:_____________________________________________________________________
Begin date: _________________________End date: _________________________________
Position: ____________________________________Charge experience: Yes ❏ No ❏
Specialty/Unit: ________________ ____________________
Have you floated to other units? Yes ❏ No ❏ If so, please list: ________________________
Number of beds in facility: ____________________Teaching facility? Yes ❏ No ❏
Number of beds in unit: _________________Nurse/patient ratio: ______________________
Immediate supervisor: __________________Supervisor phone: _______________________
Reason for leaving: ___________________________________May we contact? Yes ❏ No ❏
Healthcare Staffing Employment Application
Education
Nursing School: _____________________________State: ___________________________
Year Graduated: ______________Degree/Diploma: __________________________________
Present Specialty/Area of Interest: ________________________________________ Years of Exp: ______
Other Specialty: ________________________________________________________Years of Exp: ______
Emergency Information
In case of emergency, please notify: ______________________Relationship: ____________
Address:___________________________________________Phone_____________________
City: _______________________State: ____________________Zip:_____________________
I understand that all employees of Nurses 911 LLC must undergo drug screens and criminal checks. I agree ❏ I
disagree ❏
While I am on assignment for Nurses 911 LLC I am responsible for maintaining licensure/certification relevant to my
assignment. I give Nurses 911 LLC right to investigate my past employment, education and activities related to the
position for which I am applying. I understand that employment is contingent on satisfactory references. I release from all
liability; persons, companies, and corporations who provide information. I release Nurses 911 LLC from any liability that
might result from this investigation. All information obtained will be the property of Nurses 911 LLC
By signing this document I am agreeing to the above statement. I am also confirming that the statements made in this
application are true to the best of my knowledge. I understand that any false information will be the basis for
disqualification of employment or termination of services.
Signature________________________________________ Date________________________
PLEASE FORWARD ALL COMPLETED APPLICATIONS TO:
EMAIL: myrecruiter@travelnurses911.com
or
FAX 866-706-0834 (Attention Human Resources)