Superior Medical Staffing Application Form
You must have at least 1 years applicable experience to be considered.
Position Applying for:
First Name

Last Name

Maiden and/or Other Names
Street Address
City State ZIP Code
Current Phone
Permanent Phone
Cell Number
E-mail Address
Social Security Number

Name of Emergency Contact

Phone Number of Emergency Contact
Referred By
Date available for Contract Positions:
Shift Preference: 1st , 2nd , 3rd
Licenser:
State , Number , Exp. Date:
State , Number , Exp. Date:
State , Number , Exp. Date:
Certifications
CPR , Exp Date
BCLS , Exp Date
ACLS , Exp Date
PALS , Exp Date
NALS/NRP , Exp Date
CCRN , Exp Date
CEN , Exp Date
Other , Exp Date
Education (Month/Year) Passed State Boards State
College Name Location
Month/Year of Graduation Diploma/Degree
Graduate School Name Location
Month/Year of Graduation Diploma/Degree
Other Name Location
Month/Year of Graduation Diploma/Degree
Has your professional license or certification ever been investigated or suspended?
Yes , No
If Yes please explain
Are you eligible for rehire at all previous and current positions?
Yes , No
If No please explain
Malpractice Insurance Policy Number , Company
Policy Expiration Date a copy of this policy will be required
Health Condition
Excellent , Good , Fair
Are you employed now? Yes , No
If so, may we contact your current employer? Yes , No
Employment History
Employer
Department
Address
Phone
Position Held
Supervisor
Dates of Employment
Reason for Leaving
May we contact? Yes , No
Was this travel? Yes , No
Was this Agency? Yes , No
Employer
Department
Address
Phone
Position Held
Supervisor
Dates of Employment
Reason for Leaving
May we contact? Yes , No
Was this travel? Yes , No
Was this Agency? Yes , No
Employer
Department
Address
Phone
Position Held
Supervisor
Dates of Employment
Reason for Leaving
May we contact? Yes , No
Was this travel? Yes , No
Was this Agency? Yes , No
Employer
Department
Address
Phone
Position Held
Supervisor
Dates of Employment
Reason for Leaving
May we contact? Yes , No
Was this travel? Yes , No
Was this Agency? Yes , No