Nurse Staffing Company and Nurse Staffing Services - Angel Healthcare Staffing
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Nurse Staffing Company and Nurse Staffing Services - Angel Healthcare Staffing
Home Nurse Staffing Company - About Us Per Diem Nurse - Caregivers Temporary Medical Nurse Staffing - Clients Apply Now - Application Nurse Travel Program - Travel Nurse Recruitment Agency - Contact Us
 
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Bullet Application Form
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Date Available
for Work *		    
First Name *    Middle Initial Last Name *
Current Address *
City *    State *    Zip *
Email Address *
Current Phone Number * Other Phone Number Cell
Other
Social Security Number
Can you provide proof of eligibility to work in the United States? *   Yes   No
Emergency Contact Phone Number
Emergency Contact (not living with you) Phone Number
Type of Degree * RN   LPN/LVN   CNA   Other (please specify below)
 Shift Preference * AM
PM
Either
How did you hear about Angel Healthcare?
EDUCATION
Name and Locations of School(s) Graduated Date Type of Degree
* *  *
        
        
        
LICENSURE
(Please list all including expired)
Professional License/
Technical Certificate		 # * *
     
     
     
Which of these licenses is your original state of licensure? *
Has your license or certification ever been under investigation? * Yes    No
If YES, please explain
Has your license or certification ever been revoked or under suspension? * Yes    No
If YES, please explain
Resuscitation Credential Expiration Date
ACLS    
BLS    
ENPC    
NRP    
PALS    
TNCC    
PROFESSIONAL CONTINUING EDUCATION
Course Name Date CEUs Earned
   
   
   
   
Have you ever been convicted of a felony that would prohibit your employment at a health care facility? *
Yes    No
Have you ever been convicted of a felony in the past five years? * Yes    No
Are you currently employed? * Yes    No
Do you have any physical or mental conditions that would inhibit or restrict your ability to perform the essential functions of your job? * Yes    No
If YES, what are they?
Do you have one year of acute care experience in the past two (2) years? * Yes    No
PLEASE CHECK ALL THAT APPLY:
I would like to be considered for travel positions with Angel Healthcare Staffing
Travel Cities:

I would like to be considered for local positions with Angel Healthcare Staffing
City/Cities Desired Locations:

EMPLOYMENT EXPERIENCE
Begin with your current or last job.
Provide, in chronological order, your last four (4) employers.
Include any gaps of employment with a brief description.
Current/Last Employer * Phone
Address
City *    State *    Zip
Supervisor
  May this person be contacted for a reference? Yes   No
Job Title * Specialty/Unit
Employment Dates From *    
To    *     		Full Time    Part Time
Supervisory Experience? Yes   No Reason for
Leaving *
Comment
Current/Last Employer Phone
Address
City    State    Zip
Supervisor
  May this person be contacted for a reference? Yes   No
Job Title Specialty/Unit
Employment Dates From    
To         		Full Time    Part Time
Supervisory Experience? Yes   No Reason for
Leaving
Comment
Current/Last Employer Phone
Address
City    State    Zip
Supervisor
  May this person be contacted for a reference? Yes   No
Job Title Specialty/Unit
Employment Dates From