Employment Application

Application
Name:*

First NameLast Name
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Cell Phone:*

Area CodePhone Number
E-mail Address:*
Availability Date:*
Education
Name of School/University
City
State
Degree/Certification Obtained:
Month/Year Graduated
Experience
Current Position:
What Specialty/Modality are you currently in?
Certifications
Certification:
Expiration Date:
Certification:
Expiration Date:
Certification:
Expiration Date:
Certification:
Expiration Date:
Licensure
State:
Exp Date:
Compact:
License #
State:
Exp Date:
Compact:
License #
State:
Exp Date:
Compact:
License #
EMR/EHR Systems
List all EMR/EHR/Charting Systems you have experience with:

CernerEpicMeditechMcKessonSiemensGE HealthcareAllscriptsHealth ConnectCasambraKronosRehab OptimaOther
Work History

(Please enter in your last 3 positions held)
Facility Name:*
City*
State*
Start Date*
End Date*
Position Held:*
Specialty:*
Travel Assignment?*
Facility Name:
City
State
Start Date
End Date
Position Held:
Specialty:
Travel Assignment?
Facility Name:
City
State
Start Date
End Date
Position Held:
Specialty:
Travel Assignment?
Resume
If You Would Like To, Please Upload Your Resume Here....
Upload Resume:

Browse Files

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Upload Resume:

Upload a File

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References

Please list two (2) MANAGER/CHARGE references within the past year
Name:

First NameLast Name
Title
Facility Where You Worked With Them:
Best Contact Phone Number

Area CodePhone Number
E-mail Address
Reference 2
Name:

First NameLast Name
Title
Facility Where You Worked With Them:
Best Contact Phone Number

Area CodePhone Number
E-mail Address
Have you ever been convicted of a crime other than a minor traffic violation?*

YESNO
If YES please explain....
Have you ever been named as a defendant in a professional liability action?*

YESNO
If YES please explain....
Has action ever been taken against your professional license?*

YESNO
If YES please explain....
Are you already working with a Skyline Med Staff recruiter? If so, let us know who.
I certify the information contained in this application is true, correct, and complete. I understand that, if employed, false statements reported on this application may be considered sufficient cause for dismissal.
Digital Signature*
Date*

MonthDayYear
Date
Should be Empty:

Application

Education

Experience

Certifications

Licensure

EMR/EHR Systems

Work History

Resume

References

Reference 2