Profile  Data:

First Name M.I. Last Name

Maiden Name or other names you have Practiced under

Present Address (Street/City/State/Zip Code):

Permanent Address (If Different from above):

Home Phone #:  Cell Phone #:

Fax#:   Pager#:

Are you a US Citizen?

Email Address:

Have you ever previously applied/contracted or been hired by our Company? Yes No

Have you ever worked for any Travel/Staffing Companies? Y/N Yes No

List Agencies:

Are you eligible for re-hire with the Travel/Staffing Companies? Yes No

Have you ever been Convicted of a felony? Y/N    If yes, Please explain

Profile Personal Preferences:

Date Avail to Start?  Shift Preference: Day Evening Nights  

Can you work  MonTue Wed Thu Fri   Weekends  Holidays

Are you Looking to: Travel  Per Diem  or Permanent Placement

List Areas or Places you would like to Travel to:

Are their any facilities you will not work at?

License Information

What type of Licensure do you hold?  RN     LPN      CST      CNA

 Please list State/License #/Expires

Other License:

Certifications

BLS  Date Taken:      Expires:

ACLS Date Taken:   Expires:

PALS Date Taken:   Expires:

TNCC  Date Taken:   Expires:

NALS/NRP  Date Taken:    Expires:

EKG COURSE Date Taken:   Expires:

CNOR Date Taken:    Expires:

Other Certification:

Has your License ever been suspended, revoked, & or under investigation? No Yes

If Yes, Please explain?

Malpractice Insurance

Do you currently have Malpractice insurance Coverage? Yes No

Exp Date

Name of  Insurance Company                  

Education

High School City/State   Date Graduated   Degree

College City/State   Date Graduated   Degree

College City/State   Date Graduated   Degree

References- Work Related

 Reference Name                                                       
Title
Address (Street/City/ State/Zip Code)
Phone #
Cell #
Where did you work with this reference?
How Long did you work with this reference?

Reference Name                                                       
Title
Address (Street/City/ State/Zip Code)
Phone #
Cell #
Where did you work with this reference?
How Long did you work with this reference?

Reference Name                                                       
Title
Address (Street/City/ State/Zip Code)
Phone #
Cell #
Where did you work with this reference?
How Long did you work with this reference?

Emergency Contact Information

 Emergency Contact Name                  
Relationship
Address (Street/City/ State/Zip Code)
Phone #
Cell #

Employment History

Business Name Supervisor

Business Address

Phone #Dates Employed

Position Duties

Department Eligible for rehire? Yes No

Business Name Supervisor

Business Address

Phone #Dates Employed

Position Duties

Department Eligible for rehire? Yes No

Business Name Supervisor

Business Address

Phone #Dates Employed

Position Duties

Department Eligible for rehire? Yes No

Business Name Supervisor

Business Address

Phone #Dates Employed

Position Duties

Department Eligible for rehire? Yes No

Business Name Supervisor

Business Address

Phone #Dates Employed

Position Duties

Department Eligible for rehire? Yes No

I certify that the statements herein are true and complete. I understand that false, misleading, or omitted information is basis for disqualification from employment/contract or ineligibility for hire. I authorize Platinum Nursing, llc to investigate All information reported in this application/profile and authorize all employers, agents, physicians, nurses, contractors, authorizing agencies, or any authorized representatives to release information concerning my performance, conduct, and condition of health. I agree to hold harmless from any liability for any cause, except willful falsification of data arising from the release and use of said information those who provide said information and those to whom this information is provided.

Please insert your name as an electronic signature and authentication that all the information provided is accurate.

Electronic Signature:    Date:

Please only hit Submit Once ... we will notify you when we receive the completed application.