Application

Name

Address

Mobile phone

Best time(s) to call

How did you find us? (optional)

If you were referred, what is their name (we'd like to thank them)? (optional)

Qualification Text

Qualification

Job title

Your specialty

Years of experience

Are you certified?

Yes No

Certification

Active state licenses (optional)

Do you have prior travel experience?

Yes No

Do you have a current BLS?

Yes No

Is your BLS issued through the American Heart Association?

Yes No

References Text

References

Reference Instruction Text

Please submit 2 supervisor/manager references from the past year. If you are a traveler, please provide a supervisor reference from your most recent travel assignment.

Reference Header

Reference #1

Name

Facility

Title

Phone Number

Best time(s) to call

Employment dates

Reference Header

Reference #2

Name

Facility

Phone Number

Best time(s) to call

Employment dates

Reference Header

Reference #3

Name

Facility

Title

Phone Number

Best time(s) to call

Do we have permission to reach out to these references?

Yes No Please wait. Let's discuss first.

References Text

Availability

I can start a new contract on this date

I need these dates off

Shift preference

Travel preference

Have my own car and will drive Will fly and use public transportation to get around Will fly and may need a rental car Depends on the distance to assignment

Will you be traveling with a pet?

Yes No

Housing

I'm a self provider and want to arrange my own housing Prefer to have AMS arrange my housing

Location preference

Open to anywhere Lets discuss it and come up with the best game plan for me Specific geographic areas and/ or states (specify below) A certain radius or drive time from home (specify below)

Please specify location (optional)

References Text

Background

1) Has your license or certification ever been investigated or suspended?

Yes No

2) Have you ever been named as a defendant in a professional liability action?

Yes No

3) Have you ever been convicted of a crime other than a minor traffic violation?

Yes No

If you answered "Yes" to one of the above background questions (1 - 3), please explain (optional)

References Text

Upload files

Resume

Recommendation letters (optional)

Records (optional)

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Reference #3

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