Online Application

Online Application

Online Application
(Fields marked with * and areas in gray are all required)

Personal Information

First Name*

Middle Name

Last Name*

Primary Phone*

Secondory Phone

Email*

Current Address*

City*

State*

ZIP*

Same as current address

Permanent Address

City

State

ZIP

Driver's License Number

State

Expiration
Date

(mm/dd/yyyy)

Shift Preference

Referred By

Who is your Emerald Recruiter?*

Emergency
Contact Name*

Relationship

Phone*

Date available for work*

(mm/dd/yyyy)

(Must be greater than today's date)

Are you a military veteran?*

YES NO

Nursing Licensure (Active) (Must fill in State Lincense, License#, and Expiration date.)
State License	License#	Expiration Date(mm/dd/yyyy)
		(required*)

Has your nursing license ever been investigated, suspended or revoked?*	YES NO

Have you ever been convicted of a crime other than a minor traffic violation?*	YES NO

At any time in your career have you been denied malpractice insurance?*	YES NO

Can you submit verification of your legal right to work in the United States?*	YES NO

Education (Please enter most recent degree first.) (Must fill in Name of School, City, State, Year, and Degree)
Name of School	City	State	Year	Degree
				(required*)

Certifications (Please list all certifications - i.e., BCLS, ACLS, NRP, PALS, Fetal Monitoring, etc.)
(Must fill in Type and Expiration date. Cannot enter duplicate certifications)

Type	Expiration Date(mm/dd/yyyy)
	(required*)

Specialties and Unit Experience
Please identify the recent Primary unit experience(s) you have had (in years) in each of these units. In addition, identify the unit(s) that you could float by placing a check in the Float column next to unit name. Greater flexibility with Float experiences translates into more opportunities for staffing assignments.

(Must fill in Specialty and Primary Exp. Floating Ability is optional. Cannot enter duplicate Specialty)

Specialty	Primary Exp. (# of Years)	Floating ability
			(required*)

Clinical References

Please provide us with two Clinical References that we can contact. Please make sure these Clinical References are (A) People who have managed you (i.e. Charge Nurse, Unit Manager, Director, etc...), (B) from within the past year and (C) from the Clinical Unit in which you would most like a Travel Assignment (for example, if your first choice is an L&D Travel Assignment, please make sure your Clinical References are from an L&D unit).

Reference #1
Reference's Name*		Title*		Clinical Unit*
Facility Name*
Primary Phone*	--	Secondary Phone	--
From*	(mm/yyyy)	To*	(mm/yyyy)
Facility Address
City*		State*		ZIP

Reference #2
Reference's Name*		Title*		Clinical Unit*
Facility Name*
Primary Phone*	--	Secondary Phone	--
From*	(mm/yyyy)	To*	(mm/yyyy)
Facility Address
City*		State*		ZIP

Co-Worker References
First Name*	Last Name*	Phone*	--
License Held*	Relationship*	How long known?*	year(s)

First Name	Last Name	Phone	--
License Held	Relationship	How long known?	year(s)

First Name	Last Name	Phone	--
License Held	Relationship	How long known?	year(s)

Current/Most Recent Employment Details
Facility Name*		Dept/Unit*
Address		City*
State*		ZIP
Dates Employed: From*	(mm/yyyy)	To*	(mm/yyyy)
Reason for Leaving*		Title
Shift worked*
Position Type*		Charge Experience?	YES NO
Name of Travel/Registry company (if applicable)
Supervisor's Name*		Phone*	-- Ext.
Other Supervisor?		Phone	-- Ext.

Previous Employment History(Please try and cover the last 3-5 years of experience)

Employment Details (Section-1)

Facility Name		Dept/Unit
Address		City
State		ZIP
Dates Employed: From	(mm/yyyy)	To	(mm/yyyy)
Reason for Leaving		Title
Shift worked
Position Type		Charge Experience?	YES NO
Name of Travel/Registry company (if applicable)
Supervisor's Name		Phone	-- Ext.
Other Supervisor?		Phone	-- Ext.