nurses

As an esteemed healthcare provider your unique clinical skills are certainly in demand, particularly in the ever-changing and diverse world we live in.

We will strive to find the most suitable facility that will fit your need’s, which will allow you to provide the most valuable service of patient care.

We will help you succeed so that you can fulfill your goals of providing patient care that can bolster your confidence and has far reaching benefits. In short, we know that our success is assured when you succeed.

Please contact us for more information if you are interested in seeking seasonal placement, Per Diem or PRN, contract or travel work, or temporary to permanent work, we are confident that we can match your skills to a facility that suits your needs.

Nurse Registration

Personal Information

First Name

Middle Initial

Last Name

Suffix

Degree

Home Phone

Cell Phone

Address

Are you authorized to work in the United States?

Yes No

Birthplace

Date of Birth

Social Security Number

Date Available

Education and Training

Nursing School

Address

Start Date (mm/yy)

End Date (mm/yy)

Medical School

Address

End Date (mm/yy)

Start Date (mm/yy)

Graduate School

Address

Professional Certification

Certification Board

Date Certified

Certification Board

Date Certified

Re-certification Date

Clinical Certification

BLS Certification?

Yes No

BLS Expiration Date

ACLS Certification?

Yes No

ACLS Expiration Date

Date Certified

Re-certification Date

Licensure

Please enter the information for all states in which you have held a medical license.

Provider Name

State

License Number

License Status

Active Inactive

Date License Granted (mm/yy)

License Expiration Date

License

References

Please list three professional peer references that can comment upon your current (within the past year) clinical and professional capabilities.

References 1

Name

Specialty

Home Phone

Cell Phone

Address

References 2

Name

Specialty

Home Phone

Cell Phone

Address

References 3

Name

Specialty

Home Phone

Cell Phone

Address

References 3

Work History

Please list all your practice locations and employment affiliations to cover at least the past ten years of clinical practice.

Hospital/Facility

From (mm/yy)

To (mm/yy)

Contact Name

Contact Title

Phone

Address

Upload Document Here

If there are any gaps in your work history, please provide an explanation:

If you desire Backup Medical Staffing not to contact these facilities, please list them below with an explanation.

Personal health Statement

Do you have any physical or mental conditions that would compromise your ability to practice or perform appropriate clinical duties?

Yes No

Have you used drugs recreationally, had a problem with, or been treated for, alcoholism, narcotic addiction, or mental illness?

Yes No

Do you have, or have you ever had, a chronic illness or physical condition that impairs your ability to practice your specialty?

Yes No

Have you ever used, or do you now use, a controlled substance?

Yes No

Do you need any special accommodations to carry our your daily responsibilities?

Yes No

Do you have any physical or mental conditions that would compromise your ability to practice or perform appropriate clinical duties?

Yes No

Background Check Release Form

I hereby authorize Backup Medical Staffing and its designated agents and representatives to conduct a comprehensive review of my background through a consumer report and/or an investigative consumer report to be generated for employment, promotion, reassignment or retention as an employee. I understand that the scope of the consumer report/investigative consumer report may include, but is not limited to, the following areas:
Verification of Social Security Number, current and previous residences, employment history including all personnel files, education, character references, credit history and reports, criminal history records from any criminal justice agency in any or all federal, state county jurisdictions, birth records, motor vehicle records to include traffic citations and registration and any other public records.

I, Hammett Hester, authorize the complete release of these records or data pertaining to me which an individual, company, firm, corporation, or public agency may have. I understand that I must provide my date of birth to adequately complete said screening, and acknowledge that my date of birth will not affect any hiring decisions. I hereby authorize and request any present or former employer, school, police department, financial institution or other persons having personal knowledge of me, to furnish bearer with any and all information in their possession regarding me in connection with an application for employment. This authorization and consent shall be valid in original, fax, or copy form.

I hereby release Backup Medical Staffing, and its agents, officials, representatives, or assigned agencies, including officers, employees, or related personnel both individually and collectively, from any and all liability for damages of whatever kind, which may at any time, result to me, my heirs, family or associates because of compliance with this authorization and request to relapse. You may contact me as indicated below; I understand that a copy of this authorization may be given to me at any time, provided I request it in writing. Information on this application and results of the background investigation will be maintained in confidence in accordance with company hiring practices.

First

Middle (full)

Last

Maiden

Print All Former Names Used:

Documents

nurses

Nurse Registration

Personal Information

Education and Training

Professional Certification

Clinical Certification

Licensure

References

References 1

References 2

References 3

References 3

Work History

Personal health Statement

Background Check Release Form

Information

Newsletter

Socials

Address