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Suwannee Medical Personnel

Employment Application
Required fields are indicated by "•"
• First Name:
Middle Name: 
• Last Name:
• Social Security #:
• Street Address/ P.O. Box:
• City:
• State:
• Zip:
• Home Phone:
Cell Phone:
Fax:
Pager:
E-mail Address:
Emergency Contact Name:
Emergency Contact Address:
Emergency Contact Phone:
Driver's License State:
Driver's License Number:
Driver's License Expires: (mm/dd/yyyy)
• Are you legally authorized to work in the United States? Yes No
Who can we thank for your referral?
• Have you ever applied to or been employed by Suwannee Medical Personnel? Yes No
• Have you ever been convicted of any misdemeanor or felony within the last 7 years? Yes No
• Check As Appropriate:
(Certification)		 CNA
LPN
RN
EMT
PCT
MA
Sitter
Med Tech
Rad Tech
HHA
PT
PTA
OT
OTA
ST
Env Srv
Phleb
Paramedic
Recpt
Pharmacy tech
RRT
Surg Tech
CRT
MHT
CLERK
ARNP
PA-C
Cert Sonagrapher
MSW
MD
OMC-RN
Type of Employment Desired: Travel (13-26 weeks)
Per Diem
Direct Placement
Local Contract (2 to 13 wks)
Type of Shifts: 8 Hour Shifts
12 Hour Shifts
10 Hour Shifts
Other
Shift Preference: DAY
EVE
NOC
 

Professional Licensure/Certification
1. State:
License Number:
Expiration date: (mm/dd/yyyy)
2. State:
License Number:
Expiration date: (mm/dd/yyyy)
3. State:
License Number:
Expiration date: (mm/dd/yyyy)
  Expiration Date
CPR/BLS (mm/dd/yyyy)
ACLS (mm/dd/yyyy)
NALS/NRP (mm/dd/yyyy)
PALS (mm/dd/yyyy)
IV CERT (mm/dd/yyyy)
CCRN (mm/dd/yyyy)
TNCC (mm/dd/yyyy)
 

Employment History
Clinical positions most recent first
1. Employed from:
 (mm/dd/yyyy)
Employed to:
 (mm/dd/yyyy)
Facility:
Street Address:
City:
State:
Zip:
Facility Supervisor's Name:
Facility Supervisor's Title:
Facility Supervisor's Telephone Number:
Your Title:
Unit Assigned:
Number of Beds:
Was this a travel assignment?
 Employee
Travel Assignment
Reason for Leaving:
Agency name:
Area/Unit
Worked
% of the
time
In what
capacity?
 
2. Employed from:
 (mm/dd/yyyy)
Employed to:
 (mm/dd/yyyy)
Facility:
Street Address:
City:
State:
Zip:
Facility Supervisor's Name:
Facility Supervisor's Title:
Facility Supervisor's Telephone Number:
Your Title:
Unit Assigned:
Number of Beds:
Was this a travel assignment?
 Employee
Travel Assignment
Reason for Leaving:
Agency name:
Area/Unit
Worked
% of the
time
In what
capacity?
 
3. Employed from:
 (mm/dd/yyyy)
Employed to:
 (mm/dd/yyyy)
Facility:
Street Address:
City:
State:
Zip:
Facility Supervisor's Name:
Facility Supervisor's Title:
Facility Supervisor's Telephone Number:
Your Title:
Unit Assigned:
Number of Beds:
Was this a travel assignment?
 Employee
Travel Assignment
Reason for Leaving:
Agency name:
Area/Unit
Worked
% of the
time
In what
capacity?
 
 
Education Information
What is the highest clinical degree/certification received?
1. School Name, City & State:
Area of Concentration:
Year Graduated from School:
Degree Type:
2. School Name, City & State:
Area of Concentration:
Year Graduated from School:
Degree Type:
Do you carry professional liability insurance? Yes No
If yes, any pending claims? Yes No

Explain:
What professional, trade, business or civic associations do you belong to?
Special accomplishments, publications, or awards?
 
• Please select, from the following, the skill/unit in which you have one year experience in the past 24 months as primary care:
SFHC
TMC
SOUTH DET
PAR
ORIENTATION MED SURG
MAINT
NURSING HOME
CORRECTIONAL
MED SURG
ICU
PCU
CCU
SITTER
TELE
ER
PRIVATE
HOMECARE
TCU
PSYCH
HOSPICE
OB/MB
L&D
SCHOOLS
MOB
PEDS
ORIENTATION
OR
SICU
PACU
MICU
CHS
CVSD
DIALY
DETOX
CLINIC
REHAB
RESP
ADULT
ADOL
NICU
IMC
PICU
CARDCATH
INDUSTRIAL
ORTHO
RAD
CATH LAB
HIGH TECH
ROUTINE
ON CALL
TRAVEL
H/K
ADMISSION
F/OFFICE
B/OFFICE
Phleb
SSD
Dental
PHARMACY TECH
SMP ADMIN EVAL
List other acute sub specialties for which you are qualified and would like to work:
Clinical Experience: (Number of Years)
 
Assignment Preferences
Location:
Where do you want to go?
Describe your ideal position:
When are you available to start? (mm/dd/yyyy)
In selecting your next assignment, what is your most important consideration?
 
Upload Your Resume
Copy and Paste your resume below

4000 Character Limit (equivalent to 1 1/3 pages, 12 pt. type single spaced)
 

SEXUAL/RACIAL HARASSMENT POLICY
It is the policy of Suwannee Medical Personnel that employees have the right to work in an environment free of any form of sexual or racial harassment. If you feel that you have been sexually or racially harassed, please call your Suwannee Medical Personnel Representative immediately. In the event that you are unable to contact them, please feel free to contact our corporate office. Any associate who advises us of a possible harassment situation will not suffer repercussions due to the voicing of the complaint.

WORKER’S COMPENSATION POLICY
Suwannee Medical Personnel strives to have a safe environment for our employees to work in. In the event you are injured while on an assignment, you must call our office immediately. If you feel unable to call, please ask your supervisor to contact us. You must immediately report any injuries no matter how minor they may seem. Any claims not reported immediately may be subject to denial. Suwannee Medical Personnel will work together with both the client and the employee for the proper procedure and treatment of the injury.

By clicking "Continue" I agree that:
I have read and fully understand the questions asked in this application and that all answers given by me are true, accurate, and complete. I also understand that the omission, concealment, or misrepresentation of any fact on this application or during any interview for employment and be cause for my immediate dismissal from employment.

I give the Company permission to use any information in this application to enable it and its agents to verify the information contained in this application, and I authorize present and former employers, educational institution I have attended, credit agencies, all references, and any other persons to answer all questions asked by the Company, Suwannee Medical Personnel may conduct a criminal background investigation and that my employment with the Company may be contingent upon the results of such investigation. I release the Company, its agents, and all affiliated entities, as well as any person or institutions that provides the Company with any information about me, from any and all liability whatsoever resulting from any such investigation or the disclosure of such information.

In consideration of my employment and of my being considered for employment by Suwannee Medical Personnel, I agree to abide by all Company rules and regulations, which I understand are subject to change by the Company at any time for any reason without prior notice. I also understand that if employed, I will be an employee at will and employed for no definite period of time. I understand that either the company or I can terminate my employment at an time, with or without cause and with or without advance notice. I further understand that no communication, whether oral or written, by any representative of the Company, at any time, can constitute a contract of employment. No representative or agent of the company other than the Director of Human Resources by either written or mutually signed agreement, has the authority to enter into any agreement for employment for any specific period of time or to make any agreement contrary to the foregoing.

In addition, I understand that the Company and all compensation and benefits plan administrators have the maximum discretion permitted by law to administer, interpret, modify, discontinue, enhance, or otherwise administer, interpret, or change all policies, procedures, benefits, or other terms and conditions of employment.

I am willing to submit to a physical examination, including the analysis for the detection of the use of unlawful drugs or substances in accordance with applicable laws. If I receive an offer of employment at the request of the Company and if one is given, I agree that my continued employment may be contingent on the results.

I agree, inconsideration of your employing me, that I will not seek or accept employment, either directly or indirectly in any capacity from any client of Suwannee Medical Personnel to whom I have been assigned, for at least 180 working days after the last day of that assignment. I also agree that I will not solicit these clients on my behalf nor on behalf of any future employer(s). I further understand that I cannot be paid until I present a time slip signed by both the client and me to the Suwannee Medical Personnel office.

I understand that Suwannee Medical Personnel does not provide auto insurance coverage for me and that I am not to transport patients in my automobile, nor am I to drive patients in the patient’s automobile without written consent from Suwannee Medical Personnel.