Quik Travel Staffing - Full-time Permanent Nursing Employment Page. Dialysis Nursing jobs available now. Nursing Employment. Employment Agency for Nurses.

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General Information

First Name:

Last Name:

Middle Initial:

Email:

Home Phone:

Work Phone:

Cell Phone:

Permanent Home Address:

City:

State:

Zip Code:

What type of employment are you seeking:

Travel

Per-Diem

Permanent Placement

Local Contract

(You may check more than one)

Date Available:

Travel Location Preference:

(If applicable)

Are you eligible to work in the US:

Yes

How did your hear about QT Staffing:

If you were referred, who referred you:

Emergency Contact Information

Emergency Contact Name:

Relationship:

Emergency Phone Number:

Discipline & Specialty

Discipline:

Specialty:

Years of experience in your current specialty:

Professional License(s)

Home State License:

Additional State License(s):

(Separate with comma, i.e.: CA, TX, NV )

Certification(s)

List of Certifications:

(Separate with comma, i.e.: BLS, CNN, CCHT)

Background Information

Has your liscense or certification ever been investigated or suspended?

Yes

If yes, please give details and current status.

Have you ever been convicted of a crime other than a minor traffic accident:

Yes

If yes, please give details and current status:

Medical Systems

What computerized charting systems are you most familiar with?

If applicable, what dialysis machines are you most familiar with?

Education #1

School (1):

Degree:

Graduation Date:

City:

State:

Country:

Education #2

School (2):

Degree:

Graduation Date:

Education City:

Education State:

Education Country:

Employment History #1

Employer Name (1):

Agency (if applicable):

City:

State:

Start Date:

End Date:

Position:

Reason for leaving:

Unit Type:

Type of employment (Travel, Per-Diem, Staff Position):

Supervisor's Name:

Supervisor's Title:

Supervisors's Phone:

Employment History #2

Employer Name (2):

Agency (if applicable):

City:

State:

Start Date:

End Date:

Position:

Reason for leaving:

Unit Type:

Type of employment (Travel, Per-Diem, Staff Position):

Supervisor's Name:

Supervisor's Title:

Supervisors's Phone:

Employment History #3

Employer Name (3):

Agency (if applicable):

City:

State:

Start Date:

End Date:

Position:

Reason for leaving:

Unit Type:

Type of employment (Travel, Per-Diem, Staff Position):

Supervisor's Name:

Supervisor's Title:

Supervisors's Phone:

FULL APPLICATION