OnLine Application
Answer all questions completely. Applications are evaluated on completeness and accuracy.
Position applying for: Specialization:
First Name: Last Name:
Address:
City, State ZIP: ,  
Email Address: DOB:
Social Security Number:
Home Phone: Cell Phone:
Other Phone:
Emergency Contact: Emergency Phone:
What type of work are you interested in?
What date will you be available?
What is the best way to contact you?
How did you find this site?
Name of the person who referred you:
List any languages other than English that you speak

Length of Assignment Desired:
6 wk 8 wk 13 wk

Is this your first travel assignment?:

Can you provide verification of your legal right to work in the U.S.?:

Are you able to perform the basic functions of the postion for which you are applying with or without reasonable accomodations?:

Have you ever been convicted of a crime that would prohibit your employment in a healthcare facility?:

Have you ever had disciplinary action taken against any license, or are you currently the subject of a report or investigation?:

Are you willing to submit to a criminal background investigation?:
Education
School or College Location Graduation Date Degree
Certifications
Certification Expiration Date Certification Expiration Date
BLS ACLS
PALS NALS
NRP TNCC
CHEMO CNOR
CCRN
Licensure
State License Number Expiration Date
Employment (most recent first)
Date Employed:      From to May we contact?   Yes  No
Employer: Position:  
Specialty/Unit: # of beds:  
Average patient ratio: Charge Experience:   Yes  No
Reason for leaving:
Immediate Supervisor: Business phone:  
Date Employed:      From to May we contact?   Yes  No
Employer: Position:  
Specialty/Unit: # of beds:  
Average patient ratio: Charge Experience:   Yes  No
Reason for leaving:
Immediate Supervisor: Business phone:  
Date Employed:      From to May we contact?   Yes  No
Employer: Position:  
Specialty/Unit: # of beds:  
Average patient ratio: Charge Experience:   Yes  No
Reason for leaving:
Immediate Supervisor: Business phone:  
Date Employed:      From to May we contact?   Yes  No
Employer: Position:  
Specialty/Unit: # of beds:  
Average patient ratio: Charge Experience:   Yes  No
Reason for leaving:
Immediate Supervisor: Business phone:  
Date Employed:      From to May we contact?   Yes  No
Employer: Position:  
Specialty/Unit: # of beds:  
Average patient ratio: Charge Experience:   Yes  No
Reason for leaving:
Immediate Supervisor: Business phone:  

Release Form:

  1. Western Staffing is dedicated to providing quality healthcare professionals.  Always be on time and look your very best.  Adhere to the dress code and follow rules and regulations of the hospital. 
  2. Assignments are offered on a first come – first serve basis.  We inform the hospital of your availability, shift preferences, and specialty.  While the hours and days of work are set forth and explained in the interview, these are not guaranteed during your employment and you may be required to work shifts, hours, or areas, as organizational needs require.  You will be required to float to areas of competency.  If you feel that you are being asked to float to an area other than the area you are competent to work, please call your Western Staffing Representative immediately, 24/7.  (888-764-0067)
  3. Salary will be discussed when the position is offered.  Your salary is confidential and should be discussed only with your recruiter.  Failure to adhere to this policy could result in termination.  Employees receive their paychecks weekly.  Federal withholding taxes and FICA are with held from you in accordance with Federal laws.  State taxes are withheld accordingly.  Western Staffing will observe the same holidays as the hospital where you are assigned.  Time and one half is paid for hours worked on holidays, and overtime over 40 hours per week, unless otherwise specified.  Time sheets will be provided for you.  You are responsible for faxing your time sheet on Monday mornings before 10:00 A.M.  (1-877-764-1334)  No payroll checks can be issued until time sheets are in the office and approved. 
  4. Professional licensure must be verified and on file prior to employment. 
  5. Employees are hired on the basis of character, references, qualifications and their ability to perform their duties competently.  Employees are required to have one-year current hospital experience. 
  6. Western Staffing is an equal opportunity employer.  Employees are hired without regard to race, color, creed, national origin, age, or gender. 
  7. Application for employment and all other forms completed, including W-4 and I-9 forms, become a part of your permanent record.  Any misrepresentation of facts or misstatements made on these records will be grounds for dismissal. 

Please Read Carefully Before Submitting These Guidelines

I understand and acknowledge that no guaranteed or fixed employment term has been offered to me.  I authorize Western Staffing to investigate all statements in my application and to secure any necessary information from all my employers, references, and academic institutions.  I hereby release all of those employers, references, academic institutions, and Western Staffing from any and all liability arising from their giving or receiving information about my employment history, medical history and physical exam, my academic credentials or qualifications, and suitability for employment with Western Staffing.  I authorize any physician or hospital to release any information which may be necessary to determine my ability to perform the essential functions of the job for which I am hired or being considered.  I hereby agree to submit to any lawful drug, alcohol or other testing that may be required as a condition of employment and understand that refusal to submit to such testing during the course of my employment may result in termination.  I hereby authorize Western Staffing to obtain a background check before placing me on an assignment and throughout employment with Western Staffing.  Western Staffing may, upon facility’s request, conduct background checks of any kind from any location for any purpose Western Staffing considers reasonable.  Applicant also gives permission for release of the results for determining fitness of employment and/or continued employment.   I agree and understand that any offer of employment I may receive is contingent upon my successful completion of Western Staffing pre-employment screening, including any physical examination that may be required.  I have read and I agree to meet Western Staffing minimum requirements of the position for which I am being hired.  I will comply with all rules, regulations, and policies of Western Staffing.  No promises regarding employment have been made to me, and I understand that Western Staffing guarantees no such promises unless made in writing and signed by a representative of Western Staffing.

Applicant states that he/she has obtained education and training in the healthcare field and is duly licensed and authorized to practice nursing.

You have the right to contact Joint Commission, at any time, without fear of retribution from Western Staffing.

Western Staffing is an equal opportunity employer.

 I certify that I have read, understand and agree to the above conditions of employment.


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