Candidate Application

Personal Information
US CitizenPerm ResidentF-1 Visa HolderH-1 Visa Holder/Need H-1 VisaTN Permit HolderOther
Education
Experience
Certifications
Licensure
Yes
Yes
Yes
Yes
Yes
EMR/EHR Systems
Cerner Epic (EpicCare, etc.) Meditech McKesson (Horizon, etc.) Siemens GE Healthcare (Centricity, etc.) Allscripts Health Connect
Other
Cerner Epic (EpicCare, etc.) Meditech McKesson (Horizon, etc.) Siemens GE Healthcare (Centricity, etc.) Allscripts Health Connect
Other
Work History (please list last 7 years, no gaps. Most recent first)
Facility Name:
Employed From:To:
City/State/Zip:
Position Held:Specialty:
Shift Times:Average Patient Ratio:
# of Beds in Unit:# of Beds in Facility:
Reason for Leaving:
Clinical Reference:Reference Phone #:
Can we contact reference?Yes NoTeaching Facility?Yes No
Charge Experience?Yes NoTravel Assignment?Yes No
If Yes, what agency?
Facility Name:
Employed From:To:
City/State/Zip:
Position Held:Specialty:
Shift Times:Average Patient Ratio:
# of Beds in Unit:# of Beds in Facility:
Reason for Leaving:
Clinical Reference:Reference Phone #:
Can we contact reference?Yes NoTeaching Facility?Yes No
Charge Experience?Yes NoTravel Assignment?Yes No
If Yes, what agency?
Facility Name:
Employed From:To:
City/State/Zip:
Position Held:Specialty:
Shift Times:Average Patient Ratio:
# of Beds in Unit:# of Beds in Facility:
Reason for Leaving:
Clinical Reference:Reference Phone #:
Can we contact reference?Yes NoTeaching Facility?Yes No
Charge Experience?Yes NoTravel Assignment?Yes No
If Yes, what agency?
Work History (please list last 7 years, no gaps. Most recent first)
Employer:Dates: (mth/yr-mth/yr)
**If Travel Assignment/Per Diem work list agency name:
City, State:Position:
Employer:Dates: (mth/yr-mth/yr)
**If Travel Assignment/Per Diem work list agency name:
City, State:Position:
Employer:Dates: (mth/yr-mth/yr)
**If Travel Assignment/Per Diem work list agency name:
City, State:Position:
Employer:Dates: (mth/yr-mth/yr)
**If Travel Assignment/Per Diem work list agency name:
City, State:Position:
Employer:Dates: (mth/yr-mth/yr)
**If Travel Assignment/Per Diem work list agency name:
City, State:Position:
Employer:Dates: (mth/yr-mth/yr)
**If Travel Assignment/Per Diem work list agency name:
City, State:Position:
Employer:Dates: (mth/yr-mth/yr)
**If Travel Assignment/Per Diem work list agency name:
City, State:Position:
Please explain any gaps in Work History, including Month and Year (to complete full 7 years):
I certify the information contained in this application is true, correct, and complete. I understand that, if employed, false statements reported on this application may be considered sufficient cause for dismissal.
Name:Date: