As Needed Staffing, Inc.
Placement Profile
Please fill out application entirely, incomplete applications will delay processing. Fields with an asterisk (*) must be filled out or your application will not be processed.
       
    General Information  
 
   *First Name: Middle
    *Last Name:
          *Address:
                  *City:
         *State:  *Zip Code:
*Home Phone:
     Cell Phone:
         *Email: 
How should we reach you?
      Method:
         Time:
Professional Discipline: 
RN: LPN: LVN: CMA: CNA:
Other:
Specialty: 
      Primary:
 Secondary:
        Other:
Experience:
  *Years of Experience:
Tell us about you:
Give us a brief description of your strengths, experience, skills and personal qualities that would be attractive to a hospital. How would you be an asset to a hospital? ...This information will help immensely in your placement.
Placement Information:
Work preference:   Travel PRN Any
* Date you wish to start with As Needed Staffing, Inc.
What Shift do you prefer: Day Eve Noc Any
If you prefer PRN how far from home are you willing to go: Miles 
Travel Choices:  
  First Choice
       State     City
    
   Are you licensed in this state?  Yes No
  Second Choice
       State     City
    
   Are you licensed in this state?  Yes No
  Third Choice
       State     City
    
   Are you licensed in this state?  Yes No
How did you here about As Needed Staffing? 
            
I acknowledge that checking the box marked "yes" below, is equivalent to my personal written signature as it confirms my consent to and assurance of the truthfulness and validity of the information I have submitted on this form:
      Yes Date  

 

 


Copyright © 2002 [As Needed Staffing, Inc.]. All rights reserved.
Revised: March 10, 2002 .