MEDRelief Staffing ~ Candidates - Applicant Profile: Staffing services for diagnostic, imaging, and healthcare professionals - radiology, nursing, respiratory, laboratory

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Applicant Profile

for Nursing Professionals

Please complete the following applicant profile.
Fields in bold type are required.
Please click the button at the end of the form to send this form to us or you may print it and fax it to the number below.

800.342.6704	[toll-free telephone]
866.250.5321	[toll-free fax]


First Name	Last Name
Permanent Address
City		State	Zip
Current Address (if different from above)
City		State	Zip
Daytime Phone	XXX-XXX-XXXX
Evening Phone	XXX-XXX-XXXX
E-mail Address
Best time to contact you
State & License Number
Additional Licenses
Certifications (check all that apply)	RN LVN MA CNA Med Surg L & D CCRN ER OR	ICU NICU Geriatrics Pediatrics Psychiatry Oncology Telemetry PACU Clerical
	Other: Please specify:
Current Experience (check only one)	Less than 1 year 1-2 years 2-5 years 5-10 years More than 10 years
Criminal History	Have you ever been convicted of a felony or a crime? Yes No
	If yes, please explain:
Interested in (check all that apply)	Local (Houston area) Full-Time Long-Term 13+ wks Temp to Perm	Travel (outside Houston) Part-Time Short-Term PRN
Shift Preferences (check all that apply)	Days Weekends	Nights Holidays
Availability	Now	Date
Travel Preferences	1st Travel Choice	2nd Travel Choice
	Geographic preference
	Traveling with pets? Yes No
	If yes, please specify type and weight (in pounds): lbs.
Referral Source (check all that apply)	MEDRelief Employee: Name Newspaper Friend: Name Catalog Postcard AHEC class Web site E-mail Ad in Nursing Careers Today Ad on Monster Ad on CareerBuilder Search engine ~ please specify: Link from another site ~ please specify: Medical facility/medical journal ~ please specify:
Additional Comments or Questions

After you click the Submit Information button,
please e-mail us and attach your resume in Word or PDF format, if you have one.

Thank you!