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Traveler Application

Your journey is about to begin!

Thank you for your interest in becoming a member of the National Healthcare Staffing family. There are 2 options for completing the application.

  1. Download our application, fill out and sign where indicated, and fax back to your personal recruiter at .
  2. Fill out the on-line application below.

After you submit your application, your personal recruiter will contact you shortly.

Quick Form

To contact National Healthcare Staffing without completing your application please sign-up now.

On-line Application

All fields in blue with an * are required

Personal Information
Last *
First *
Middle initial
Social Security number (000-00-0000)*
Email address *
Professional discipline *
Specialty
Date available to travel
How did you learn about our company?
Date *

Permanent address
Street address *
City, state, zip , *
Phone *
Best time/day to reach you

Current address
Street address
City, state, zip
Home phone
At this location until
Work phone

Licensure
State Expiration date
State Expiration date
State Expiration date

Certification
Check one: Certified Registered Registry Eligible
Other:
Certificate: Registration / Registration number
Expiration date
Has your professional license or certification ever been investigated or suspended? Yes No *
If yes, please give details and current status:
Have you ever been convicted of a crime other than a minor traffic violation? Yes No *
If yes, please give details and current status:
Have you ever been named as a defendant in a professional liability action? Yes No *
If yes, please give details and current status:
Can you submit verification of your legal right to work in the U.S.? Yes No *
If you will be employed on a visa, please specify type of work visa:

Education

College name
Date graduated
Diplomas, Degrees received
City, state

Graduate school name
Date graduated
Diplomas, Degrees received
City, state

Other school name
Date graduated
Diplomas, Degrees received
City, state

In case of emergency
Person to notify in case of emergency
Relationship
Street address
City, state, zip
Phone

Employment history
Please indicate all of your employment for the past ten (10) years, beginning with your most recent employer. Please list each facility in which you have worked.
Are you employed now? Yes No
If so, may we contact your present employer? Yes No
Other names under which you have been employed

Facility/Employer #1
Facility/employer
Department
Street address
City, state, zip
Dates employed: From: To:(mm/dd/yyyy)
Reason for leaving
Position held
Specialty
Supervisor's name
Phone
Other supervisor?
Phone
Travel assignment? Yes No
Local staff agency? Yes No

Facility/Employer #2
Facility/employer
Department
Street address
City, state, zip
Dates employed: From: To:(mm/dd/yyyy)
Reason for leaving
Position held
Specialty
Supervisor's name
Phone
Other supervisor?
Phone
Travel assignment? Yes No
Local staff agency? Yes No

Facility/Employer #3
Facility/employer
Department
Street address
City, state, zip
Dates employed: From: To:(mm/dd/yyyy)
Reason for leaving
Position held
Specialty
Supervisor's name
Phone
Other supervisor?
Phone
Travel assignment? Yes No
Local staff agency? Yes No

Facility/Employer #4
Facility/employer
Department
Street address
City, state, zip
Dates employed: From: To:(mm/dd/yyyy)
Reason for leaving
Position held
Specialty
Supervisor's name
Phone
Other supervisor?
Phone
Travel assignment? Yes No
Local staff agency? Yes No

Facility/Employer #5
Facility/employer
Department
Street address
City, state, zip
Dates employed: From: To:(mm/dd/yyyy)
Reason for leaving
Position held
Specialty
Supervisor's name
Phone
Other supervisor?
Phone
Travel assignment? Yes No
Local staff agency? Yes No

Facility/Employer #6
Facility/employer
Department
Street address
City, state, zip
Dates employed: From: To:(mm/dd/yyyy)
Reason for leaving
Position held
Specialty
Supervisor's name
Phone
Other supervisor?
Phone
Travel assignment? Yes No
Local staff agency? Yes No

Facility/Employer #7
Facility/employer
Department
Street address
City, state, zip
Dates employed: From: To:(mm/dd/yyyy)
Reason for leaving
Position held
Specialty
Supervisor's name
Phone
Other supervisor?
Phone
Travel assignment? Yes No
Local staff agency? Yes No

Facility/Employer #8
Facility/employer
Department
Street address
City, state, zip
Dates employed: From: To:(mm/dd/yyyy)
Reason for leaving
Position held
Specialty
Supervisor's name
Phone
Other supervisor?
Phone
Travel assignment? Yes No
Local staff agency? Yes No

Facility/Employer #9
Facility/employer
Department
Street address
City, state, zip
Dates employed: From: To:(mm/dd/yyyy)
Reason for leaving
Position held
Specialty
Supervisor's name
Phone
Other supervisor?
Phone
Travel assignment? Yes No
Local staff agency? Yes No

Facility/Employer #10
Facility/employer
Department
Street address
City, state, zip
Dates employed: From: To:(mm/dd/yyyy)
Reason for leaving
Position held
Specialty
Supervisor's name
Phone
Other supervisor?
Phone
Travel assignment? Yes No
Local staff agency? Yes No

Facility/Employer #11
Facility/employer
Department
Street address
City, state, zip
Dates employed: From: To:(mm/dd/yyyy)
Reason for leaving
Position held
Specialty
Supervisor's name
Phone
Other supervisor?
Phone
Travel assignment? Yes No
Local staff agency? Yes No

Attestation

The statements made in this application are true to the best of my knowledge. I understand that any falsification will be the basis for disqualification of employment or termination of services. I authorize National Healthcare Staffing, LLC ("National") to verify the information I have provided and to contact past employers and references concerning my ability, character and employment record. I release all such persons from liability for furnishing said information. I authorize National, as my employer, to release any medical information which may be relevant to my employment to their client facilities. By submitting this application to National, I authorize release of this information to all other affiliates of National and I acknowledge and agree that they may contact me using facsimile or any other means. Nothing contained in this employment application, or in the granting of an interview, is intended to create an employment contract between National and the applicant for either employment or for providing of any benefit. All offers of employment are made conditional upon the applicant's proving employment authorization and identity in accordance with the Immigration Reform and Control Act of 1986.