Advanced Medical Personnel, Inc. - specializes in fulfilling the staffing needs of businesses and medical facilities

Advanced Medical Personnel - offering nationwide placement services

Job Application

Printable application (pdf)

In order to qualify, you must have one year of acutecare experience within the last two years and your license must be in good standing.

Sections marked with * are required

* First Name

Middle name

* Last Name

* Email Address

* Home Address

Apt/Suite etc.

* City

* State

* Zip Code

* Current Phone Number

Permanent Phone Number

SSN

Birth Date
(MM/DD/YY) Required upon employment.

* Can you provide proof of eligibility to work in the United States?

Yes

* Emergency Contact
(not living with you)

Name

Phone

* Type of Profession

RN	CRNA	LPN/LVN
Respiratory Therapist	Radiology Tech	Certified Surgical Tech or Tech

If other, please specify.

Personal Referral
Name of Referrer

Have you spoken to a Recruiter or Branch Director?

If you have spoken to a recruiter or branch director please be sure to enter their name.

Yes	Recruiter Name

Education
Please list the schools that you have attended below.

* a.

Name	Location
Graduated (Date)	Type of Degree

Name	Location
Graduated (Date)	Type of Degree

Name	Location
Graduated (Date)	Type of Degree

Name	Location
Graduated (Date)	Type of Degree

Licensure
Please list any Professional Licenses and/or Technical Certificates you have below.

* a.

State

Exp. Date

State

Exp. Date

State

Exp. Date

State

Exp. Date

* Which of these licenses is your original state of licensure?

Type Of License

* Has your license or certification ever been under investigation?

Yes

If YES, please explain

* Has your license or certification ever been revoked or under suspension?

Yes

If Yes, please explain

Professional Certifications
(Please list all certifications. Ex., CCRN, RNC-NICU, OCN, CRRN)

Type

Exp. Date

Type

Exp. Date

Type

Exp. Date

Type

Exp. Date

Resuscitation Credentials
Please indicate your resuscitation credential(s) by placing the expiration date next to the appropriate credential.

ACLS

BLS

ENPC

NRP

PALS

TNCC

Professional Continuing Education

Course Name

Date

CEUs Earned

Course Name

Date

CEUs Earned

Course Name

Date

CEUs Earned

Specialties and Unit Experience
Please indicate the amount of experience - IN YEARS - you have worked in the following specialties/units.

Critical Care - Adult

Bone Marrow Transplant ICU

Time (years)

Float

Burn ICU

Time (years)

Float

Cardiac ICU

Time (years)

Float

Cardiac Catheterization Lab

Time (years)

Float

Cardiothoracic ICU

Time (years)

Float

Cardiovascular ICU

Time (years)

Float

Emergency Room

Time (years)

Float

Medical ICU

Time (years)

Float

Neuro ICU

Time (years)

Float

Neurosurgical ICU

Time (years)

Float

Transplant ICU

Time (years)

Float

Trauma ICU

Time (years)

Float

Surgical ICU

Time (years)

Float

Critical Care - Pediatric

Burn ICU - Peds

Time (years)

Float

Cardiac Catheterization Lab

Time (years)

Float

Emergency Room - Peds

Time (years)

Float

Pediatric ICU

Time (years)

Float

Pediatric - Transplant ICU

Time (years)

Float

Other

Please specify

Intermediate Care - Adult

Cardiac SD/Telemetry Unit

Time (years)

Float

Endoscopy Lab

Time (years)

Float

Surgical Step-down Unit

Time (years)

Float

Intermediate Care - Pediatric

Pediatric Step-down Unit

Time (years)

Float

Other

Please specify

Medical Surgical - Adult

Admitting/Observation Unit

Time (years)

Float

Diabetic Unit

Time (years)

Float

Gastrointestinal Unit

Time (years)

Float

General Surgery Unit

Time (years)

Float

Genitourinary Unit

Time (years)

Float

Geriatric Unit

Time (years)

Float

Gynecology Unit

Time (years)

Float

Hematology Unit

Time (years)

Float

Hemodialysis Unit

Time (years)

Float

Home Health

Time (years)

Float

Hospice Unit

Time (years)

Float

Med Surg Unit

Time (years)

Float

Renal Unit

Time (years)

Float

Neurology Unit

Time (years)

Float

Oncology Unit

Time (years)

Float

Orthopedic Unit

Time (years)

Float

Outpatient Clinic

Time (years)

Float

Pulmonary Unit

Time (years)

Float

Radiology Services

Time (years)

Float

Rehabilitation Unit

Time (years)

Float

Skilled Nursing Facility

Time (years)

Float

Medical Surgical - Pediatric

General Peds Unit

Time (years)

Float

Oncology Unit

Time (years)

Float

Home Health

Time (years)

Float

Hospice Unit

Time (years)

Float

Rehabilitation Unit

Time (years)

Float

Other

Please specify

Perioperative

Pre-op Holding or Monitoring

Time (years)

Float

Operating Room

Time (years)

Float

Cardiovascular OR

Time (years)

Float

Cystoscopy Suite

Time (years)

Float

ENT/Ophthalmology OR

Time (years)

Float

General Surgery OR

Time (years)

Float

Neurosurgical OR

Time (years)

Float

Orthopedic OR

Time (years)

Float

Transplant OR

Time (years)

Float

Post Anesthesia Care Unit/ RR

Time (years)

Float

Same Day Surgery

Time (years)

Float

Perinatal

Antepartum Unit

Time (years)

Float

Labor & Delivery

Time (years)

Float

High Risk Labor & Delivery

Time (years)

Float

LDRP

Time (years)

Float

Mother Baby Unit

Time (years)

Float

NICU, Level 2

Time (years)

Float

NICU, Level 3

Time (years)

Float

Newborn Nursery

Time (years)

Float

Postpartum Unit

Time (years)

Float

Other

Please specify

Psychiatry - Adult

General Psychiatric Unit - Adult

Time (years)

Float

Chemical Dependency Unit-Adult

Time (years)

Float

Dual Diagnosis Unit - Adult

Time (years)

Float

Locked Psychiatric Unit - Adult

Time (years)

Float

Other

Please specify

Psychiatry - Pediatrics

Adolescent Psychiatric Unit

Time (years)

Float

Dual Diagnosis Unit - Adolescent

Time (years)

Float

Pediatric Psychiatric Unit

Time (years)

Float

Other

Please specify

Specialty Skills
Please identify any of the skills listed below for which you have completed an organized training course and which you have at least six months experience.

Skills:

Arrhythmia Interpretation

Intra-Aortic Balloon Pump

Chemotherapy Administration

Intracranial Pressure Monitoring

Credentialed

IV Conscious Sedation

Circulating OR Skills

IV Catheter Insertion

CVVN, CAVH, or CRRT

LVAD

ECT

Mechanical Ventilation

ECMO

PICC Line Insertion

Fetal Monitoring

Peritoneal Dialysis

Hemodialysis

Scrub OR Skills

Sheath Removal

Transport Skills

Additional Information

* Have you been convicted of any law violation? Include any plea of "guilty" or "no contest." Exclude minor traffic violations.

Yes

* If YES please give details. (A conviction will not necessarily disqualify an applicant from employment.)

*Are you currently employed?

Yes

If YES, may we contact your employer?

Yes

* Do you have any physical or mental conditions that would inhibit or restrict your ability to perform the essential functions of your job?

Yes

If YES, would you be requesting any accommodations to aid you in fulfilling the essential duties of your job?

Yes

If YES, what are they?

* Do you have one year of acute care experience in the past two years?

Yes

Please check all that apply

I would like to be considered for Travel Nursing positions where I may need to travel to an assignment.

I would like to be considered for positions with U. S. Nursing where a labor dispute may exist.

Employment Experience
Start with your present or last job.

* Employment Dates
(mm/dd/yy)

From

Salary

Beginning

Ending

* Hospital/Facility

Agency (if used)

* Full Time

Yes

* Part Time

Yes

*Address

* City

* State

*Zip Code

* Immediate Supervisor

* Specialty/Unit

*Types of Patients

*Number of Beds

*Supervisory experience?

Yes

Was this a supplemental assignment?

Yes

* Reason for leaving

Employment Dates
(mm/dd/yy)

From

Salary

Beginning

Ending

Employer

Full Time

Yes

Part Time

Yes

Address

City

State

Zip Code

Immediate Supervisor

Specialty/Unit

Types of Patients

Number of Beds

Supervisory experience?

Yes

Was this a supplemental assignment?

Yes

Reason for leaving

Employment Dates
(mm/dd/yy)

From

Salary

Beginning

Ending

Employer

Full Time

Yes

Part Time

Yes

Address

City

State

Zip

Immediate Supervisor

Specialty/Unit

Types of Patients

Number of Beds

Supervisory experience?

Yes

Was this supplemental assignment?

Yes

Reason for leaving

	I certify that I have read, understand and intend to comply with the Applicant Agreement and that the facts contained in this application are true and accurate. I understand that any misrepresentation or omission of facts is cause for dismissal. I authorize the employer to investigate any and all statements contained herein and request the persons, firms, and/or corporations named above to answer any and all questions relating to this application. I release all parties from all liability, including but not limited to, the employer and any person, firm or corporation who provides information concerning my prior education, employment or character: I understand that by selecting "Yes, I accept this agreement" below that I have read, understood and intend to comply with the Applicant Agreement . For Corporation: Advanced Medical Personnel, Inc 10 Mountain View Avenue, Suite 1020, Bay Point, CA 94565 For Applicant:

	* Applicant Name
	*Applicant Address
	* Do you accept this agreement?	YES NO
	* Today's Date