Last Name * First Name * Middle Name Previous Surname. Discipline * Social Security Number DOB Address * Nick Name

(1)

IDENTIFYING INFORMATION

Last Name * First Name * Middle Name Previous Surname

Discipline * Social Security Number DOB E-Mail Address * Nick Name

Date Available (mm/dd/yyyy) Day Phone * Evening Phone Best time/day to reach you

How did you hear about us? If referred, by whom?

CURRENT ADDRESS

Address 1 * Address 2

City * State/Province Zip/Postal Code Country *

At Current Address Until (mm/dd/yyyy)

PERMANENT ADDRESS

Address 1 Address 2

City State/Province Zip/Postal Code Country

Day Phone Evening Phone

EMERGENCY CONTACT

Name Relationship Phone

SPECIALTIES Primary Specialty * # Years of Experience

Secondary Specialty # Years of Experience

Additional Specialty # Years of Experience

LICENSES State/Province License Number Expiration Date (mm/yyyy) Compact

Yes No

State/Province License Number Expiration Date (mm/yyyy) Compact

Yes No

CERTIFICATIONS Certification Type * Date Issued (mm/yyyy) Expiration Date (mm/yyyy)

Certification Type * Date Issued (mm/yyyy) Expiration Date (mm/yyyy)

(2)

TRAVELER APPLICATION

MEDICAL SYSTEMS

Computerized Charting System you are MOST familiar with Additional Computerized Charting Systems with which you are familiar

Machines you are MOST familiar with Additional Machines with which you are familiar

EDUCATION School * Degree * Graduation Date (mm/yyyy) *

City * State/Province Country *

School * Degree * Graduation Date (mm/yyyy) *

WORK EXPERIENCE

Facility/Worksite Name * Facility/Worksite Phone Agency Contracted through (If applicable)

City * State/Province Country &

State Date (mm/yyyy) End Date (mm/yyyy) Position * Reason for Leaving

Other Reason for Leaving (if “Other” is selected above as Reason for Leaving)

Unit Type * Sub-Specialty Nurse/Patient Ratio Unit Size/Number of Beds

Float To Shift Type of Assignment *

(3)

Clinical Supervisor Name Clinical Supervisor Title Clinical Supervisor Phone May we contact for reference? *

Teaching Facility? Trauma Center? Worked Charge?

Notes (facility size, types of patients, floating experience)

WORK

EXPERIENCE Facility/Worksite Name * Facility/Worksite Phone Agency Contracted through (If applicable)

(4)

TRAVELER APPLICATION

WORK EXPERIENCE

WORK EXPERIENCE

(5)

WORK EXPERIENCE

(6)

TRAVELER APPLICATION

PROFESSIONAL REFERENCES - Please list at least three (3) professional references within your specialty with whom you have had CLINICAL contact in the past one year. They

must be able to assess your professional skills and capabilities. Verbal references will be kept confidential. When possible, please let the reference know. RNnetwork will be calling.

Name* Position/Relationship* Specialty* Home/Cell Phone #

Work Phone #* Fax # Email

Address City State Zip Code*

Country* Started Work From (MM/YYYY)* Ended Work From (MM/YYYY)*

ADDITIONAL INFORMATION

Can you submit verification of your legal right to work in the U.S. *

Are there any reasons that would prevent you from competently performing the job-related functions of a traveler? *

If yes, please explain

(7)

ACTIONS &

SANCTIONS

Have you ever been employed where your employment was terminated by the employer?* If yes, please explain

Have malpractice claims, lawsuits, settlements, or judgments been made against you?* If yes, how many? Has your malpractice insurance coverage ever been denied, limited (excluded from any specific procedures), or canceled? *

Do you have your own professional liability insurance coverage?* Do you have your own professional liability insurance coverage?*

Have you ever been placed on probation, terminated, or placed under any disciplinary action during your training program?