Full Application

Last Name

First Name/Middle Initial

RN LPN PT OT ST Other

Current Street Address Line 1

Current Street Address Line 2

City

State

Zip Code

Current Day Time Phone:

E-Mail Address

Permanent Street Address Line 1

Permanent Street Address Line 2

City

State

Zip Code

Social Security Number

Date Available Example: 01-08-00 --

How did you hear of Shamrock Medical Staffing, Inc?

LICENSURE:

State

Expiration Date: example 01-10-00 --

Additional Licenses Held:

State

Expiration Date: example 01-10-00 --

State

Expiration Date: example 01-10-00 --

CERTIFICATIONS:

CPR Expiration Date

PALS Exp. Date

ACLS Expiration Date

Other

NALS/NRP Exp. Date

Has your License ever been investigated or revoked in any jurisdiction that you have been licensed in. Yes No

If yes give details and the current status of your license

Can provide proof of your legal right to work in the US Yes No

If you will be employed on a visa, Please specify type of work visa:

EDUCATION:

College/School

Location

Graduation Month/year - Degree

College/School

Location

Graduation Month/year - Degree

College/School

Location

Graduation Month/year - Degree

Emergency Contact:

Name:

Street Address:

City

State

Zip Code

Phone:

EMPLOYMENT HISTORY:

List Most Recent First
Indicate all employment, if working as a Travel or Contract Employee
Indicate the specific facility that you worked in.

Are you currently employed? yes No

May we contact your present employer? yes No

Resume

Facility/Employer:	Department/Unit/Floor:
Address:	City:	State:	Zip Code:
Employment Dates: (Month/Year)
From: - (example: 01-99)	To: - (example: 01-99)	Reason for leaving:
Position held:
Size of unit/dept:	Shift worked:
Type of unit/dept   Supervisory of charge experienceyes, no
Supervisor's (Name and Title):	Phone:	Ext:
Travel assignment?  Yes No    Local staffing agency? Yes No

Facility/Employer:	Department/Unit/Floor:
Address:	City:	State:	Zip Code:
Employment Dates: (Month/Year)
From: - (example: 01-99)	To: - (example: 01-99)	Reason for leaving:
Position held:
Size of unit/dept:	Shift worked:
Type of unit/dept   Supervisory of charge experienceyes, no
Supervisor's (Name and Title):	Phone:	Ext:
Travel assignment?  Yes No    Local staffing agency? Yes No

Facility/Employer:	Department/Unit/Floor:
Address:	City:	State:	Zip Code:
Employment Dates: (Month/Year)
From: - (example: 01-99)	To: - (example: 01-99)	Reason for leaving:
Position held:
Size of unit/dept:	Shift worked:
Type of unit/dept   Supervisory of charge experienceyes, no
Supervisor's (Name and Title):	Phone:	Ext:
Travel assignment?  Yes No    Local staffing agency? Yes No

The information provided in this application is true, correct and complete. I acknowledge that any misstatement or omission of fact on ths application may result in my disqualification from consideration by Shamrock Medical Staffing, Inc. I authorize Shamrock Medical Staffing, Inc. to release this application and reference information to Shamrock Medical Staffing, Inc. client institutions, only after receiving my express written or verbal consent for each assignment opportunity.