Road Trip Nursing Full Profile

Privacy Policy
Please have a recruiter contact me:
Choose your Profession:
RN
LPN
OR Tech

Specialty:     # of years 
First Name: (required)
Middle Initial:
Last Name: (required)
Social Security Number:
Date of Birth:
Phone Number: (required)
Phone Number: (additional)
E-Mail Address: (required)
Permanent Address:
City:
State/Province:
Country:
Zip/Postal Code:
Permanent Phone:
Current Address:
City:
State/Province:
Country:
Zip/Postal Code:
Present Phone:
Will be at this location until:
Best time of day to reach you:
 Additional Information:
Type of Referral: (required)
How did you hear about PPR? Please be specific: (required)
Region, State, City, Preferences:
Have you ever applied to us before?
 yes no
If so, when?:
Desired length of assignment:
Specialty Preference:
Date you can start:
Geographic Preference:
Shift Preference:
Do you plan to travel with pets?
 yes no
Type of pet(s)
 
 Certifications:
Certification Exp. Date
(mo/yr)		   Certification Exp. Date
mo/yr)
CPR   CEN
ACLS   TNCC
BCLS   CRRN
PALS   CCRN
NALS   CHEMO
CNOR   OCN
OTHER
 
 Licenses:
State License # Exp. Date
(mo/yr)
 
Have you ever had any disciplinary action taken against any of your licenses?
Please type "yes" or "no" (Required)
Are you currently under investigation or pending discipline from any Board of Nursing jursidiction?
Please type "yes" or "no" (Required)
Have you ever been named as a defendant in a malpractice claim?
Please type "yes" or "no" (Required)
Have you ever been convicted of, or entered a plea of guilty, nolo contendere, or no contest to, a crime in any jurisdiction other than a minor traffic offense? You must include all misdemeanors and felonies, even if adjudication was withheld. Driving under the influence (DUI) or driving while impaired (DWI) is not a minor traffic offense for purposes of this question.
Please type "yes" or "no" (Required)
If so, please include all misdemeanors and felonies, even if adjudication was withheld. Driving under the influence (DUI) or driving while impaired (DWI) is not a minor traffic offense for purposes of this question.
Do you hold a nursing license under any other name?
yes no
If so, please list name:
Current Driver's License#
State:
Exp. Date:
Do you have the legal right to work in the United States and do you have documentation of that right?
 yes no
Related Courses/Certification (i.e., Chemotherapy, EKG, Balloon Pump, etc.)
 Employment History
May we contact your present employer?
 yes no
May we contact your previous employers?
 yes no
 Most Recent
Hospital:
City:
State:
Date employed:
 from to
Position held:
Specialty unit(s) worked:
Shift:
Reason for leaving:
Average patient ratio:
Number of beds in unit:
Number of beds in hospital:
Was this a travel assignment?
 yes no
Which agency?
Type of nursing:
Did you have a supervisory role?
Immediate supervisor:
Phone:
 Second Most Recent
Hospital:
City:
State:
Date employed:
 from to
Position held:
Specialty unit(s) worked:
Shift:
Reason for leaving:
Average patient ratio:
Number of beds in unit:
Number of beds in hospital:
Was this a travel assignment?
 yes no
Which agency?
Type of nursing:
Did you have a supervisory role?
Immediate supervisor:
Phone:
 Third Most Recent
Hospital:
City:
State:
Date employed:
 from to
Position held:
Specialty unit(s) worked:
Shift:
Reason for leaving:
Average patient ratio:
Number of beds in unit:
Number of beds in hospital:
Was this a travel assignment?
 yes no
Which agency?
Type of nursing:
Did you have a supervisory role?
Immediate supervisor:
Phone:
 EDUCATIONAL BACKGROUND
College or University:
College or University City:
College or University State:
Graduated?
 yes no
Graduation Year
Diplomas, Degrees Received:
Nursing School or University:
Graduated?
 yes no
Graduation Year
Diplomas, Degrees Received:
Graduate School:
Graduated?
 yes no
Graduation Year
Diplomas, Degrees Received:
List any other skills or attributes which you feel make you exceptionally qualified for a position with this company:
 3 PROFESSIONAL REFERENCES
Name 1
Hospital/Title
Phone Number
Name 2
Hospital/Title
Phone Number
Name 3
Hospital/Title
Phone Number
 3 ADDITIONAL REFERENCES(not required)
Name 1
Hospital/Title
Phone Number
Name 2
Hospital/Title
Phone Number
Name 3
Hospital/Title
Phone Number
 EMERGENCY CONTACT
Name:
Relation:
Address:
City:
State:
Home Phone:
Work Phone:
 EMPLOYMENT WAIVER
I understand and agree that:

This is an application for employment and in no way a contract. Job duties and hours may vary from the original preference.

Any withholding of information, making false statements or misrepresentation of fact on this application could result in rejection for employment, or, if employed, termination of employment.

A medical examination, as stipulated by PPR, is required for employment. Any offer of employment is contingent upon the results of the examination in consideration of the Americans with Disabilities Act guidelines.

I authorize the PPR to investigate my driving record, my criminal record and my credit history, and I understand that an investigative consumer report may be prepared whereby information is obtained through personal interviews with neighbors, friends and others with whom I am acquainted.

I authorize and request the persons, schools, law enforcement agencies, and other organizations or employers named in this application (except as noted) to provide PPR with any relevant information that may concern employment. I understand that a criminal background check and pre-employment drug testing is part of the PPR employment process. I understand that the results of the criminal background check , pre-employment drug screen and health forms may be made available to PPR clients before starting an assignment as a PPR employee. I waive the right to review any references received.

Any offer of employment is contingent upon the results of the criminal background check and pre-employment drug testing.

I further understand that the PPR may contact my previous employers and I authorize those employers to disclose to the PPR all records and other information pertinent to my employment with them. I also authorize the PPR to provide truthful information concerning my employment with it to my future prospective employers and I agree to hold it harmless for providing such information.

I understand and voluntarily agree that if hired, I will complete all educational courses and take all tests necessary to keep all of my licenses, including drivers' license, and certifications current and valid, as required by the PPR or local, state or federal law or regulation. I further agree to advise the PPR if at any time my licenses or certifications become invalid or expire. I understand that failure to take such tests when required or requested or to keep my licenses, including drivers license, current and valid or to advise the PPR that my licenses have expired or become invalid may result in my immediate dismissal.

Should a job offer be made, proof of employability and identification, as required by the Immigration Reform and Control Act of 1986, will be required prior to the first day of work.


I certify that all of the information that I provide on this application and in any interview will be true and accurate. I understand that if I am employed and any such information is later found to be false or misleading in any respect, I may be dismissed.

Please initial to show that you have read and agree to the Employment Waiver above.