CANDIDATE APPLICATION
Core Staffing LLC
Name
*
Available Date
*
/
Month
/
Day
Year
Date
Address
*
Phone Number
*
Email
*
example@example.com
Certifications include expiration date
Licensure-Please include number and note if compact
*
Has action ever been taken against your professional license? If yes, please explain.
*
Computer Charting Experience
*
EXPERIENCE
Specialty/Years Experience
*
Additional Skills
EDUCATION
School Name and Location
*
Graduated MM/YYYY
*
Degree
*
School Name and Location
Graduated MM/YYYY
Degree
Related Courses/Certifications
Facility Name
*
City/State
*
Position Held
*
Unit Worked
*
Shift
*
Average Patient Ratio
*
Number of Beds
*
Dates employed (Must be MM/YYYY-MM/YYYY format)
*
Reason For Leaving
*
Was this a travel assignment?
*
Teaching facility?
*
Charge Experience?
Explain any employment gaps
Facility
City/State
Position Held
Unit Worked
Shift
Average Patient Ratio
Number of Beds
Dates Employed must be MM/YYYY-MM/YYYY
Reason for Leaving
Was this a travel assignment?
Teaching Facility?
Charge experience?
Explain any employment gaps
Facility
City/State
Position Held
Unit Worked
Shift
Average patient ratio
Number of beds
Dates employed must be MM/YYYY-MM/YYYY
Reason for leaving
Was this a travel assignment?
Teaching facility
Charge experience
Explain any gaps in employment
Agreed and Submitted by
Date
/
Month
/
Day
Year
Date
Submit
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