Brown Medical Staffing – Clinician Application
Complete the required clinician, licensure, availability, and reference details, then upload your resume and credentials to be considered for Florida staffing opportunities.
Applicant Information
Full Legal Name
*
First Name
Middle Name
Last Name
Preferred Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
City
*
State
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
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
Other
ZIP Code
*
Professional Role
Professional Role
*
Registered Nurse (RN)
Licensed Practical Nurse (LPN)
Certified Nursing Assistant (CNA)
Advanced Practice Registered Nurse (APRN)
Unlicensed Assistive Personnel (UAP)
Other healthcare professional
If Other, specify role/title
Licensure & Certifications
License/Certification Number
*
Issuing State
*
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
District of Columbia
Other
Expiration Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current and Active?
*
Yes
No
Compact/Multistate License?
*
Yes
No
Not Applicable
BLS Status
*
Current
Expired
Not Held
BLS Expiration Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
ACLS Status
*
Current
Expired
Not Held
ACLS Expiration Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Other Certifications and Details
Experience
Total years of healthcare experience
*
Years of experience in selected role
*
Specialties / clinical areas
*
Adult Med-Surg
Pediatrics
ICU
ER
Telemetry
Operating Room
Labor & Delivery
Psychiatric
Geriatrics
Urgent Care
Other
Settings worked
*
Hospital
Long-term care / Skilled nursing
Behavioral health
Clinic / Outpatient
Correctional healthcare
Rehabilitation
Home health
Other
Brief work history
Most recent employer
Current employment status
*
Please Select
Employed full-time
Employed part-time
Per diem / PRN
Contract
Unemployed
Student
Retired
Other
Availability
Earliest start date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Employment preference
*
PRN
Temporary
Contract
Ongoing
Open to any
Preferred shifts
*
Day
Evening
Night
Weekends
Rotating
Open availability
Days available
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Preferred weekly hours
Willingness to travel within Florida
*
Yes
No
Maybe
Preferred travel radius (miles)
Preferred counties or areas
Documents
Resume
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Professional License/Certification
Upload a File
Drag and drop files here
Choose a file
Cancel
of
BLS Card
Upload a File
Drag and drop files here
Choose a file
Cancel
of
ACLS Card
Upload a File
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Choose a file
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of
Additional Credential
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Note
References
Reference 1 Name
*
First Name
Middle Name
Last Name
Reference 1 Relationship / Title
*
Reference 1 Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Reference 1 Email
*
example@example.com
Reference 2 Name
*
First Name
Middle Name
Last Name
Reference 2 Relationship / Title
*
Reference 2 Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Reference 2 Email
*
example@example.com
Screening & Attestations
Are you legally authorized to work in the United States?
*
Yes
No
Are you willing to complete required background screening?
*
Yes
No
Are you willing to complete drug screening if required by an assignment?
*
Yes
No
Are you able to provide required health and credentialing documentation before placement?
*
Yes
No
Attestation
*
I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that submitting this application does not guarantee employment or an assignment.
Signature
Electronic Signature
*
Date Signed
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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Submit Application
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