MedStaff: Application Form

Application Form

Fill out our application on-line today... Start working next week!

If you'd like to join our growing list of MedStaff professionals, fill out our convenient online application below. It couldn't be easier!

CHECK ONE:

Laboratory

Medical Lab Technician (MLT)
Medical Technologist (MT)

Nursing

Registered Nurse (RN)
Licensed Practical (LPN)

Occupational Therapy

Occupational Therapist (OT)
Occupational Therapy Assistant (OTA)

Physical Therapy

Physical Therapist (PT)
Physical Therapy Assistant (PTA)

Surgery

Certified Surgical Technician (CST)
Surgical Technician (ST)

Radiology

Certified Nuclear Medicine Technician (CNMT)
Radiation Therapy Technician (RadT)
Radiographic (AART)
Radiology Med. Sonography (RDMS)
Ultrasonographer (UST)

Respiratory Therapy

Certified Respiratory Therapist (CRTT)
Registered Respiratory Therapist (RRT)

I. PERSONAL PROFILE:

First Name: Initial:
Last Name:
Maiden Name:
Social Security #:
Date Available to Travel:
Hospital Preference:
Geographic Preference:
Referred By: E-mail Address:

Current Address:
City: State: ZIP:
Phone:
From: To:
Best Time to Reach You Between: A.M. to: P.M.

Permanent Address:
City: State: ZIP:
Phone:

In Case of Emergency Contact:
Relationship:
Address:
City: State: ZIP:
Phone:

Have you ever been convicted of a felony? Yes No
Have you ever been convicted of a drug-related misdemeanor Yes No
If you are not a U.S. citizen, have you the legal right to remain in the U.S.? Yes No

II. PHYSICAL RECORD:

All positions available through MedStaff include the full range of responsibilities standard to the industry. Are there any reasons why you would be unable to perform, or perform safely, any of the essential functions of the position for which you are applying?
Yes No
If yes, please explain:

Evidence of a physical exam within one year is required.

III. EDUCATION:

	Name/Location of School	Month/Year Graduated	Type of Degree
High School
Vocational/Technical
College/University
Graduate School
Other

IV. LICENSURE:

Licensed: Yes No
Registered: Yes No
License/Registry Eligible: Yes No

State of Original Licensure/Registry:

Active: Yes No
License #:

Additional Licensures/Registration:

State:	Number:	Active?
		Yes No
		Yes No
		Yes No
		Yes No
		Yes No

Has your license ever been investigated or suspended? Yes No

Do you have malpractice insurance? Yes No

If Yes:

Carrier	Number	Expiration Date

V. CERTIFICATIONS:

CPR:	Yes No	Expires:
Adult BLS:	Yes No	Expires:
Pediatric BLS:	Yes No	Expires:
ACLS:	Yes No	Expires:
PALS:	Yes No	Expires:
Neonatal Resuscitation:	Yes No	Expires:

Other Certifications

Organization	Certification #	Expiration Date

VI. SPECIALTY EXPERIENCE:

Type of Specialty:	Years of Acute Experience:

Total years of health care experience within an acute care hospital setting:

Please list any additional education, skills, experience or other relevant qualifications (i.e., foreign language) in the space provided below:

VII. EMPLOYMENT PROFILE:

LIST ALL EMPLOYMENT BEGINNING FROM TIME OF GRADUATION FROM YOUR HEALTH CARE PROGRAM.

All information must be completed, most recent employment first. Your employers will be contacted for verification. (Please list additional employers on a separate sheet of paper and fax or mail to MedStaff.)

1. Employment

Facility: Number of Beds:
City: State: ZIP:
Teaching Facility: Yes No Trauma Facility: Yes No
Charge/Mgmt. Experience: Yes No

Specialty Unit Experience:
1.	Years:	# Beds:
2.	Years:	# Beds:
3.	Years:	# Beds: