Application Name * First Name Last Name Other Name(s) Used: Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Home Phone * (###) ### #### Cell Phone * (###) ### #### Email * Best Time to Reach You: Other names under which you have been employed: Job Desired: Number of Hours: Hospital or Long Term Care: Shift Preference: Are you legally authorized to work in the United States? YES NO Have you ever filed an application with Prairie Travelers? YES NO Have you worked for other temporary staffing agencies? YES NO How did you hear about Prairie Travelers? * Pulse Website Job Service Referred Other Referred By Other Are you employed at this time? * Yes No May we contact your current employer? * Yes No Do you have a reliable means of transportation? * Yes No Do you have a current drivers license? * Yes No Will you take a pre-employment drug screen if requested? * Yes No How many consecutive evenings can you be away from home?: * What number of miles are you willing to commute for an assignment? * 200 Miles (Required Minimum) 200-300 Miles No Limitations License 1 Type * License 1 Number * License 1 State * License 2 Type License 2 Number License 2 State Certifications ACLS CHEMO PALS CPR/BLS NRP Other Primary Specialty * Primary Specialty Experience (years) Secondary Specialty Secondary Specialty Experience (years) * NURSES ONLY: Please indicate if you are capable and willing to work the following areas ER OB ICU LTC Psych Med/Surg Current or Most Recent Employer * Date of Hire * End Date * City * State * Zip Code * Hourly Rate * Job Title * Immediate Supervisor * Phone Number * Summarize nature of work performed * Reason for Leaving * Second Most Recent Employer * Date of Hire * End Date * City * State * Zip Code * Hourly Rate * Job Title * Immediate Supervisor * Telephone Number * Summarize nature of work performed * Reason for leaving * Third Most Recent Employer Date of Hire End Date City State Zip Code Hourly Rate Job Title Immediate Supervisor Phone Number Summarize nature of work performed Reason for leaving Educational Background - Professional Education/College Graduation Date Degree Major/Course of Study Years Attended City State Zip Code Country Professional Reference 1 - Name * Phone Number * Address * City * State * Zip Code * Professional Reference 2 - Name * Phone Number * Address * City * State * Zip Code * Emergency Contact * Emergency Contact Phone Number * Authorization to Release Professional Reference Information Yes Thank you for submitting this application. We will respond promptly.