*Required fields
Date of Application:
(mm/dd/yyyy)
PERSONAL INFORMATION
* Current Discipline:
Date Available to Travel:
(mm/dd/yyyy)
* First Name:
Middle Initial:
* Last Name:
Social Security:
(xxx-xx-xxxx)
* Home Phone:
Cell Phone:
Email:
Other:
* How did you hear of Sagent Healthstaff?
Internet:
Magazine:
Convention:
Referral:
Other:
ADDRESS INFORMATION
Current address
* Street address:
* City:
* State/Province:
* Zip/Postal Code:
Permanent address
Street address:
City:
State/Province:
Zip/Postal Code:
EMERGENCY CONTACT
Emergency Contact:
Relationship:
Telephone:
LICENSE/REGISTRATION/CERTIFICATION
License:
License Type:
State:
Expiration Date: (
mm/dd/yyyy
)
License Number:
License Type:
State:
Expiration Date: (
mm/dd/yyyy
)
License Number:
License Type:
State:
Expiration Date: (
mm/dd/yyyy
)
License Number:
License Type:
State:
Expiration Date: (
mm/dd/yyyy
)
License Number:
License Type:
State:
Expiration Date: (
mm/dd/yyyy
)
License Number:
License Type:
State:
Expiration Date: (
mm/dd/yyyy
)
License Number:
Have you taken the NCLEX? Yes
No
Certifications:
BLS:
Expiration Date:
(mm/dd/yyyy)
CEN:
Expiration Date:
(mm/dd/yyyy)
RDMS:
Expiration Date:
(mm/dd/yyyy)
RRT:
Expiration Date:
(mm/dd/yyyy)
ARRT:
Expiration Date:
(mm/dd/yyyy)
CRTT:
Expiration Date:
(mm/dd/yyyy)
ACLS:
Expiration Date:
(mm/dd/yyyy)
ENPC:
Expiration Date:
(mm/dd/yyyy)
AART:
Expiration Date:
(mm/dd/yyyy)
RNC:
Expiration Date:
(mm/dd/yyyy)
NRP:
Expiration Date:
(mm/dd/yyyy)
NMTCB:
Expiration Date:
(mm/dd/yyyy)
TNCC:
Expiration Date:
(mm/dd/yyyy)
CHEMO:
Expiration Date:
(mm/dd/yyyy)
NALS:
Expiration Date:
(mm/dd/yyyy)
PALS:
Expiration Date:
(mm/dd/yyyy)
OTHER:
Expiration Date:
(mm/dd/yyyy)
OTHER:
Expiration Date:
(mm/dd/yyyy)
ADDITIONAL INFORMATION
* Has your License or certification ever been investigated, suspended or revoked?
Yes
No
If Yes, please explain:
* Have you ever been convicted of a crime other than a minor traffic violation?
Yes
No
If Yes, please explain:
* Have you ever been named as a defendant in a professional liability action?
Yes
No
If Yes, please explain:
* Can you provide verification of your legal right to work in the U.S.A.?
Yes
No
If Visa, what type of work Visa?:
EDUCATIONAL INFORMATION
1.
College Name / Educational Institution:
City
State
Yr. Grad.
Degree
2.
College Name / Educational Institution:
City
State
Yr. Grad.
Degree
3.
College Name / Educational Institution:
City
State
Yr. Grad.
Degree
EMPLOYMENT HISTORY
Please provide your employment history for the past six years. Please start with most recent employer.
1.
* Facility/Employer Name:
* Travel Assignment:
Yes
No
* City:
* State:
* Position Held:
* Unit/Floor:
* Employment From
(mm/dd/yyyy):
* To
(mm/dd/yyyy):
* Supervisor Name & Title:
* Telephone Number:
* Reason for Leaving:
2.
Facility/Employer Name:
Travel Assignment: Yes
No
City:
State:
Position Held:
Unit/Floor:
Employment From
(mm/dd/yyyy):
To
(mm/dd/yyyy):
Supervisor Name & Title:
Telephone Number:
Reason for Leaving:
3.
Facility/Employer Name:
Travel Assignment: Yes
No
City:
State:
Position Held:
Unit/Floor:
Employment From
(mm/dd/yyyy):
To
(mm/dd/yyyy):
Supervisor Name & Title:
Telephone Number:
Reason for Leaving:
4.
Facility/Employer Name:
Travel Assignment: Yes
No
City:
State:
Position Held:
Unit/Floor:
Employment From
(mm/dd/yyyy):
To
(mm/dd/yyyy):
Supervisor Name & Title:
Telephone Number:
Reason for Leaving:
5.
Facility/Employer Name:
Travel Assignment: Yes
No
City:
State:
Position Held:
Unit/Floor:
Employment From
(mm/dd/yyyy):
To
(mm/dd/yyyy):
Supervisor Name & Title:
Telephone Number:
Reason for Leaving:
6.
Facility/Employer Name:
Travel Assignment: Yes
No
City:
State:
Position Held:
Unit/Floor:
Employment From
(mm/dd/yyyy):
To
(mm/dd/yyyy):
Supervisor Name & Title:
Telephone Number:
Reason for Leaving:
7.
Facility/Employer Name:
Travel Assignment: Yes
No
City:
State:
Position Held:
Unit/Floor:
Employment From
(mm/dd/yyyy):
To
(mm/dd/yyyy):
Supervisor Name & Title:
Telephone Number:
Reason for Leaving:
8.
Facility/Employer Name:
Travel Assignment: Yes
No
City:
State:
Position Held:
Unit/Floor:
Employment From
(mm/dd/yyyy):
To
(mm/dd/yyyy):
Supervisor Name & Title:
Telephone Number:
Reason for Leaving:
9.
Facility/Employer Name:
Travel Assignment: Yes
No
City:
State:
Position Held:
Unit/Floor:
Employment From
(mm/dd/yyyy):
To
(mm/dd/yyyy):
Supervisor Name & Title:
Telephone Number:
Reason for Leaving:
10.
Facility/Employer Name:
Travel Assignment: Yes
No
City:
State:
Position Held:
Unit/Floor:
Employment From
(mm/dd/yyyy):
To
(mm/dd/yyyy):
Supervisor Name & Title:
Telephone Number:
Reason for Leaving:
11.
Facility/Employer Name:
Travel Assignment: Yes
No
City:
State:
Position Held:
Unit/Floor:
Employment From
(mm/dd/yyyy):
To
(mm/dd/yyyy):
Supervisor Name & Title:
Telephone Number:
Reason for Leaving:
Travel Destinations/Signature
Please tell us where you’d like to travel to, who will be traveling with you (family, pets, ect.) and any other information that will help us find the right match for you.
By signing below or submitting electronically, I attest that the information provided within this application represents a full and complete disclosure of information, and is true and correct to the best of my knowledge and belief. I understand and acknowledge that failure to provide a full and complete disclosure of my employment information is a violation of the law, and could result in civil penalties. I acknowledge that any misstatement or omission of fact may result in my disqualification for participation in Sagent Healthstaff programs. I authorized Sagent Healthstaff a release this application and reference information to Sagent Healthstaff affiliates, and clients, only after receiving my express written or verbal consent for each assignment opportunity. It is understood and acknowledged that by giving Sagent Healthstaff permission to submit my application for assignment opportunities, I am also agreeing to background searches that may be required by Sagent Healthstaff, certain states or client facilities. Prior to conducting any background searches that qualify as “consumer” or “investigate consumer” reports, I will be provided separate disclosure and acknowledgment forms.
* I agree with the above statements.
Yes
* Signature:
(please type your full name)
* Date:
(mm/dd/yyyy)