Travel Assignment Application Form

Travel Assignment Application Form

Please complete all required fields to complete your Traveler Profile. PLEASE NOTE: Profile completion typically takes 2–4 business days, depending on the turnaround time for references, skills checklists, and supporting documents.
Full Name

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Position Title Applied For
Please note that a specialty-specific skills checklists will be sent to you separately via email based on your response.
Work Authorization Status: Please note that only candidates who are U.S. Citizens or Green Card holders are eligible for this position at this time.
To help us support your assignment and benefits planning, what is your health coverage preference during your assignment?
Start Date Availability

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please list your Requested Time Off (RTO) dates, if any
Upload Your Updated Resume

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License Verification

Please upload proof of license
Cancelof
BLS Certification (Certificates for renewal is acceptable)

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ACLS Certification

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NIHHS Certification (If Any)

Cancelof
Other Relevant Certification

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Reference Person 1
Reference Person 1

First NameLast Name
Reference Person 1 Email
example@example.com
Reference Person 1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Reference Person 1 Relationship to Applicant
Reference Person 1 Facility Worked Together
Reference Person 1 Dates Worked Together
I authorize Acquire Medstaff to contact this reference to verify my professional qualifications and confirm that I have obtained their permission.
Reference Person 2
Reference Person 2

First NameLast Name
Reference Person 2 Email
example@example.com
Reference Person 2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Reference Person 2 Relationship to Applicant
Reference Person 2 Facility Worked Together
Reference Person 2 Dates Worked Together
I authorize Acquire Medstaff to contact this reference to verify my professional qualifications and confirm that I have obtained their permission.
Privacy & Communication Consent
Recruiter
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Travel Assignment Application Form

Reference Person 1

Reference Person 2

Privacy & Communication Consent