Travel Nurse Application

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

First Date Available *

MM

DD

YYYY

Are you a citizen of the United States? *

Yes

No

If no, are you authorized to work in the US?

Yes

No

Have you ever worked for this company? *

Yes

No

Have you ever been convicted of a felony? *

Yes

No

Available Locations for travel:

Our nursing program is that of a traveling nurse, please select all locations you are willing to travel.

West Los Angeles

East Los Angeles

Central Los Angeles

San Fernando Valley

Orange County

San Bernardino County

Riverside County

Do you have the following? *

Mark all that apply:

None

Active Nursing License (CA)

Current CPR/First Aid Certification

Professional Liability Insurance

Licensed Social Worker

Masters in Social Work

Are you vaccinated against Covid-19? *

Yes

No

Which Vaccine Did You Choose?

Pfizer

Moderna

Johnson & Johnson

Available Times to Work: *

Anytime

Morning

Afternoon

Night

Swing/Graveyard

Experience *

Select the following services you have experience with:

Continuous Care

PRN Visit

Start of Care

Answering Service

Runner

Clinical Notes

Recertification

FU/SUPV

Discharge

Social Work Evals

Home Health Aide