Temporary RN Staff Application

1
Full Name* This field is required.
First Name
Last Name
2
Preferred Name
3
Email* This field is required.
example@example.com
4
Phone (Primary)* This field is required.
Please enter a valid phone number.
5
Phone (Alternate)
Please enter a valid phone number.
6
Home Address* This field is required.
Street Address
Apartment / Unit
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
7
I consent to be contacted by text message or phone call* This field is required.
I Agree
I Do Not Agree
8
Date of Birth* This field is required.
Month
Day
Year
9
Preferred contact method* This field is required.
Text/Call
Email
Mail
10
Social Security Number (Last 4 digits)
For identity verification and payroll setup if you are offered an assignment. Do not enter your full SSN here.
11
Work Authorization (US)* This field is required.
Yes
No
12
Require Sponsorship Now/Future?* This field is required.
Yes
No
13
Reliable Transportation* This field is required.
Yes
No
14
Do you have Driver’s License?* This field is required.
Yes
No
15
If yes, please provide the Driver’s License number
.
16
Languages Spoken
English
Spanish
Chinese
French
German
Hindi
Arabic
Russian
Portuguese
Japanese
Other
Other
17
RN License Type* This field is required.
Compact
Non-Compact
Pending
18
Primary RN License State* This field is required.
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
19
License Number* This field is required.
20
License Expiration Date* This field is required.
Date
Month
Day
Year
21
Any restrictions/discipline on any license?* This field is required.
Yes
No
22
Comments / Explanation (Restrictions or Discipline)
If you do not have details available right now, type N/A to move forward.
23
Highest Nursing Degree* This field is required.
Please Select
Please Select
ADN
BSN
MSN
DNP
Other
24
School Name* This field is required.
25
Graduation Date* This field is required.
Date
Month
Day
Year
26
Certifications Held* This field is required.
BLS
ACLS
PALS
NRP
TNCC
ENPC
NIHSS
CPI
Chemo
Moderate Sedation
Other
27
Certification Details (Issuer + Expiration Date)
Issuer (e.g., AHA)
Expiration (MM/YYYY)
BLS
Row 0, Column 0
Row 0, Column 1
ACLS
Row 1, Column 0
Row 1, Column 1
PALS
Row 2, Column 0
Row 2, Column 1
NRP
Row 3, Column 0
Row 3, Column 1
TNCC
Row 4, Column 0
Row 4, Column 1
ENPC
Row 5, Column 0
Row 5, Column 1
NIHSS
Row 6, Column 0
Row 6, Column 1
CPI
Row 7, Column 0
Row 7, Column 1
Chemo
Row 8, Column 0
Row 8, Column 1
Moderate Sedation
Row 9, Column 0
Row 9, Column 1
Other
Row 10, Column 0
Row 10, Column 1
BLS
ACLS
PALS
NRP
TNCC
ENPC
NIHSS
CPI
Chemo
Moderate Sedation
Other
Issuer (e.g., AHA)
Row 0, Column 0
Expiration (MM/YYYY)
Row 0, Column 1
Issuer (e.g., AHA)
Row 1, Column 0
Expiration (MM/YYYY)
Row 1, Column 1
Issuer (e.g., AHA)
Row 2, Column 0
Expiration (MM/YYYY)
Row 2, Column 1
Issuer (e.g., AHA)
Row 3, Column 0
Expiration (MM/YYYY)
Row 3, Column 1
Issuer (e.g., AHA)
Row 4, Column 0
Expiration (MM/YYYY)
Row 4, Column 1
Issuer (e.g., AHA)
Row 5, Column 0
Expiration (MM/YYYY)
Row 5, Column 1
Issuer (e.g., AHA)
Row 6, Column 0
Expiration (MM/YYYY)
Row 6, Column 1
Issuer (e.g., AHA)
Row 7, Column 0
Expiration (MM/YYYY)
Row 7, Column 1
Issuer (e.g., AHA)
Row 8, Column 0
Expiration (MM/YYYY)
Row 8, Column 1
Issuer (e.g., AHA)
Row 9, Column 0
Expiration (MM/YYYY)
Row 9, Column 1
Issuer (e.g., AHA)
Row 10, Column 0
Expiration (MM/YYYY)
Row 10, Column 1
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28
Other Certification Name* This field is required.
29
Other Certification Expiration* This field is required.
Date
Month
Day
Year
30
Total RN Experience* This field is required.
Please Select
Please Select
<1
1–2
3–5
6–10
10+
31
Do you want to upload documents now?* This field is required.
Yes
No
32
Resume / CV
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Select files to upload
Max. file size: 10.0MB
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33
RN License Upload
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Max. file size: 10.0MB
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34
Certifications Upload (BLS/ACLS/etc.)
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Max. file size: 10.0MB
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35
Government-issued ID Upload (optional — can be provided later)
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Max. file size: 10.0MB
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36
Payroll / Identity Document Upload (optional — provide later if requested)
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Max. file size: 10.0MB
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37
Work authorization document (optional — if applicable)
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Max. file size: 10.0MB
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38
Additional documents (optional)
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Max. file size: 10.0MB
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39
Primary Specialty* This field is required.
Please Select
Please Select
Med-Surg
Tele
ICU
ED
OR
PACU
L&D
NICU
Peds
Psych
LTC/SNF
Home Health
Dialysis
Clinic
Other
40
Years in Primary Specialty* This field is required.
Please Select
Please Select
<1
1–2
3–5
6–10
10+
41
Most Recent Unit/Department* This field is required.
42
Typical Patient Ratio
43
Patient Populations* This field is required.
Adult
Geri
Peds
Neonatal
Mixed
44
EMR Experience* This field is required.
Epic
Cerner
Meditech
Allscripts
eClinicalWorks
NextGen
Other
45
Other EMR
46
Assignment Type* This field is required.
Per Diem/PRN
Local Contract
Travel Contract
Temp-to-Perm
Permanent
47
Preferred Setting(s)* This field is required.
Acute Care
ICU/Stepdown
ED
OR/PACU
L&D/PP/NICU
Med-Surg/Tele
Behavioral
SNF/Rehab
Home Health
Dialysis
Ambulatory/Clinic
School
Corrections
Other
48
Preferred Shift(s)* This field is required.
Days
Evenings
Nights
Rotating
49
Schedule Availability* This field is required.
Weekdays
Weekends
Holidays
On-call
50
Earliest Start Date* This field is required.
Date
Month
Day
Year
51
Desired Weekly Hours* This field is required.
Please Select
Please Select
8
12
24
36
40+
52
Willing to Float (within competency)* This field is required.
Yes
No
Case-by-case
53
Travel Radius / Commute
Please Select
Please Select
5 mi
10 mi
20 mi
30 mi
50 mi
75 mi
100 mi
54
Willing to Relocate* This field is required.
Yes
No
Maybe
55
Minimum Pay Rate (Hourly)
56
Geographic Preferences
57
RTO (Requested Time Off) – next 60 days
58
Certification
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Max. file size: 10.0MB
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59
Proof of Work Authorization
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Max. file size: 10.0MB
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60
School Diploma
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Max. file size: 10.0MB
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61
Proof of Vaccination
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Max. file size: 10.0MB
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62
Other Certifications
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Select files to upload
Max. file size: 10.0MB
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