An Excellent Source for Medical Professionals

ON-LINE EMPLOYMENT APPLICATION
All *fields in Purple are required for application submission.

Materials needed for application are:

PERSONAL INFORMATION

*First Name:
Middle Initial:
*Last Name:
Social Security #:
Date Of Birth:

PERMANENT ADDRESS

*Street Address:
Apt. #:
*City:
*State/Province:
*Zip/Postal:
Country:
*Home Phone:
Cell Phone:
Pager:
*E-Mail:

PREVIOUS ADDRESS

*Street Address:
Apt. #:
*City:
*State/Province:
*Zip/Postal:
Country:

JOB INTERESTS

*Position Applying For:
*Date Available:

EDUCATION AND TRAINING

Please list all schools attended.  Begin with high school,   then list all colleges, vocational and military service schools.
High School Name
Street Address:
City:
State/Province:
Zip/Postal:

 

College/School Name
Street Address:
City:
State/Province:
Zip/Postal:
Major Emphasis:
Degree Earned?	Yes   No
Date Received:
Level And Type:
GPA:

PLEASE LIST ANY OTHER SCHOOL ATTENDED BELOW

School Name
Street Address
City:
State/Province:
Zip/Postal:
Major Emphasis:
Degree Earned?	Yes   No
Date Received:
Level And Type:
GPA:

LICENSURE INFORMATION

*License Number:	*Expiration Date:	*State:

CERTIFICATIONS

*Certificate	*Exp. Date:	*Certificate	*Exp. Date:
ACLS		CPR
BTLS/TNCC		NRP
CCRN		PALS/ENPC
CEN

NURSING SPECIALTY

*Primary:
*Secondary:

SHIFT PREFERENCE

1.
2.
3.

DAYS OF THE WEEK PREFERRED:

Mon  Tues  Weds  Thurs  Fri  Sat  Sun

GEOGRAPHIC PREFERENCE:

1.
2.
3.

DATE OF LAST PPD OR CHEST X-RAY:

Are you legally authorized to work in the USA?

Yes | No

(Should you become employed by AMS, Inc., you will be required to provide the documentation proving your eligibility to work in the USA.)

Do you have any mental or physical handicaps which would interfere with your ability to perform your job?

Yes | No

If yes, please explain briefly below:

Have you ever been convicted of any criminal offense?

Yes | No

If yes, please explain briefly below:

(A criminal conviction will not necessarily bar you from employment. We will consider the nature of the crime, the time which has expired since its occurrence and any rehabilitation you have undergone.)

Have you ever been employed by Abundant Medical Staffing, Inc.?

Yes | No

If yes, give location(s) and date(s):

Have you ever interviewed with Abundant Medical Staffing, Inc.?

Yes | No

If yes, give location(s) and date(s):

How were you referred to Abundant Medical Staffing, Inc.?
	Newspaper Trade Publication Job Fair/Open House Employment Agency AMS Employee Other

EMPLOYMENT HISTORY

List your pertinent work experience beginning with your most recent or present job. You will be asked to explain all gaps in employment. or present job. You will be asked to explain all gaps in employment.
Facility Name:
Employment Dates:	From:	MO YR
	To:	MO YR
Facility Address:
Title:
Salary:	Hourly $  or  Annually $
Describe your most recent job duties and accomplishments:

Current Supervisor:
Title:
Telephone Number:
May we contact?	Yes | No
If No, Why?
Explain reason for leaving:
Are your employment records listed under another name?
	Yes | No
If yes, what name?

 

Facility Name:
Employment Dates:	From:	MO YR
	To:	MO YR
Facility Address:
Title:
Salary:	Hourly $  or  Annually $
Describe your most recent job duties and accomplishments:

Current Supervisor:
Title:
Telephone Number:
May we contact?	Yes | No
If No, Why?
Explain reason for leaving:
Are your employment records listed under another name?
	Yes | No
If yes, what name?

 

Please list the person to notify in case of an emergency:

Name:
Address:
Relationship:
Phone:
Alternate Phone: