Apply Online For Your Next Nursing Position

All Sections marked with a red * are manditory

* PERSONAL DATA
First Name: Middle Name: Last Name:
Home Phone: Cell Phone: Fax:
Email Address:     Gender: Male Female
Address:
Address:
City: State: Zip Code:
Position Applying For:    Date Available:    
Are You a US Citizen:
Have you ever been convicted of a felony?
A conviction will not necessarily disqualify applicant from the job applied for.

* In case of emergency, please contact:
Name: Home Phone: Work Phone:
Address: City: Zip:
Relationship:

* EDUCATION
School Name Address of Institution Year. Graduated Degrees/Certificates

LICENSE INFORMATION
LICENSE TYPE: LICENSE NO: STATE: EXPIRATION DATE:
RN    
LVN    
CNA    
RN SPECIALTY    

CERTIFICATE INFORMATION
TYPE: EXPIRATION DATE:
* BLS *
PALS
Other
 
TYPE: EXPIRATION DATE:
NRP/NALS
ACLS
Other

HEALTH CARE EMPLOYMENT HISTORY FOR PAST 5 YEARS
* Employer * Dates worked
From: To:
* Address * Phone
* Supervisor Name Phone
* Reason for Leaving * Base Pay
* Position/Duties

Employer Dates worked
From: To:
Address Phone
Supervisor Name Phone
Reason for Leaving Base Pay
Position/Duties

Employer Dates worked
From: To:
Address Phone
Supervisor Name Phone
Reason for Leaving Base Pay
Position/Duties

* May we contact your present employer now for reference?
YES NO

* SKILLS ASSESSMENT
RN Skills
Burns  Cardiac Rehab. Chem. Depend.  Clinics Convalescent 
Dialysis  ER  ICU IMC  Labor+Delivery 
Med/Surg  Medical  Mobile ICU Mother/Baby  NICU 
Nursary  Oncology  Orthopedic  Outpatient Clinics  PACU 
Pediatrics  Postpartum  Psychiatry  Recovery Room  Rehabilitation 
SNF  Spinal Cord  Stepdown Unit/DOU  Surgical  TCU 
Telemetry  Triage  Urgent Care     

LVN Skills
CDU  Clinics  Convalescent  ER  IV Certified 
Med/Surg  MHU/BHU  Pediatrics  Psych  Rehab 
Sub Acute  Surgical  TELE     

CNA Skills
Hospital Only  Convalescent  SNF  Sitter  Transporter 

RN Specialty Skills
ER  GI  ICU  IMC  Infusion 
Labor+Delivery  Med/Surg  NICU  OR  PACU 
Radiology  Recovery Room  Same Day  Short Stay  Stepdown Unit/DOU 
Telemetry         

OTHER INFORMATION
Shift Preferred: 7A-3P 3P-11P 11P-7A 7A-7P 7P-7A ANY
Note any other details below which should be considered in view of your qualifications, including affiliations, honors and awards, publications, and patient recommendations.

* ACKNOWLEDGEMENTS AND ELECTRONIC SIGNATURE - Enter your initials into the box preceding the statement below to verify your understanding and to serve as your electronic signature.
* Initials I hereby certify that the information given on this form is true and correct and that I have not knowingly withheld any information regarding my employment. I authorize any employer, institution, or person(s) contacted by ALLSTAR STAFFING or this agent to furnish or verify information. Furthermore I release said employers, institutions, or person(s) from any liability for issuing information.
* Today's Date:
Day Month Year