Employment Application | Professional Nursing Service

Red text and boxes with yellow shading are REQUIRED fields.
Personal Information:
First Name:	Middle Initial:
Last Name:
Current Address:
City:
State:	ZIP:
Permanent Address:
City:
State:	ZIP:
Phone:
Emergency Phone:
Relation:
E-mail Address:
Professional Discipline:
Social Security #:
Drivers License Number:	Drivers License State:
How did you learn about PNS?
Date available to travel:
Referred by:
Referrer E-mail:

Education:
Basic Nursing Education:
Name of School:
Location of School:
Graduation Date:	Degree/Credentials Earned:
Graduate Nursing Education:
Name of School:
Location of School:
Graduation Date:	Degree/Credentials Earned:
Certificate Program/ Other:
Name of School:
Location of School:
Graduation Date:	Degree/Credentials Earned:

Professional Credentials:
Nursing Experience/Specialty Areas (Most current first):
Experience/Specialty:	Yrs:
Experience/Specialty:	Yrs:
Experience/Specialty:	Yrs:
Experience/Specialty:	Yrs:
Please indicate which of the following Recuscitation credentials you currently hold:
BCLS Exp. Date: PALS Exp. Date:
ACLS Exp. Date: NRP Exp. Date:
Other Resuscitation credentials: Exp. Date:
Please indicate any National Certifications you presently hold (eg. CCRN, CNOR):
National Cert.:	Exp. Date:
	Exp. Date:
	Exp. Date:
	Exp. Date:
Continuing Education:

Memberships in Professional Organizations:

Licensure:
Submit all licenses currently held, as well as state of original license if not currently held:
Licensure State (Original):	Exp.Date: Exp.Date:
Licensure State:	Exp.Date: Exp.Date:

References:
Please indicate all of your employment for the past ten (10) years beginning with your most recent employer: Are you employed now?Yes No If Yes, may we contact your present employer?Yes No
Most Recent Employment Information:
Facility/Employer:
Department:
Street Address:
City:
State:	ZIP:
Dates Employed:	From: To:
Reason for leaving:
Position held:
Specialty:
Supervisor's name & title:
Supervisor's phone:
Other phone:
Travel Assignment?:	Yes No
Local Staffing Agency?:	Yes No
Previous Employment Information:
Facility/Employer:
Department:
Street Address:
City:
State:	ZIP:
Dates Employed:	From: To:
Reason for leaving:
Position held:
Specialty:
Supervisor's name & title:
Supervisor's phone:
Other Supervisor's phone:
Travel Assignment?:	Yes No
Local Staffing Agency?:	Yes No
Previous Employment Information:
Facility/Employer:
Department:
Street Address:
City:
State:	ZIP:
Dates Employed:	From: To:
Reason for leaving:
Position held:
Specialty:
Supervisor's name & title:
Supervisor's phone:
Other Supervisor's phone:
Travel Assignment?:	Yes No
Local Staffing Agency?:	Yes No
Previous Employment Information:
Facility/Employer:
Department:
Street Address:
City:
State:	ZIP:
Dates Employed:	From: To:
Reason for leaving:
Position held:
Specialty:
Supervisor's name & title:
Supervisor's phone:
Other Supervisor's phone:
Travel Assignment?:	Yes No
Local Staffing Agency?:	Yes No

Other names under which you have been employed:

Reasons for periods you were not employed:
The information provided in the application for participation in the PNS Travel Program is true, correct, and complete. I acknowledge that any misstatement or omission of fact on the application may result in my disqualification from participation in the PNS program. I authorize PNS to release this application and reference information to PNS Client Institutions, only after receiving my express written or verbal consent for each assignment opportunity. I understand that by giving PNS permission to submit my application for assignment opportunities, I am also agreeing to any criminal background search that may be required by certain states or Client institutions.
I agree with the statement above:	Yes Date: