CANDIDATE APPLICATION
Core Staffing LLC
Name
First Name
Last Name
Available Date
*
/
Month
/
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Email
*
example@example.com
All Current certifications including expiration date
Licensure-Please include State. Number and note if compact
*
Professional Licensure or Certification Verified by Core Staffing, Date Verified and Source.
Verification Required by Core Staffing LLC
Has action ever been taken against your professional license? If yes, please explain.
*
To be completed by Core Staffing LLC, Professional References Verified, Source and Date verified.
Verification Required by Core Staffing LLC
To be completed by Core Staffing LLC, Annual TB Mantoux Test Date verified/Basic Life Support Training Dates Verified.
Verification Required by Core Staffing LLC
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
Most Recent Employer
*
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?
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Teaching facility?
*
Charge Experience?
Explain any employment gaps
2. Previous Employer
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
3. Previous Employer
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
By signing you agree to Core Staffing verifying a complete employment history.
Date
/
Month
/
Day
Year
Date
PLEASE ATTACH RESUME HERE.
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