Please enter your details:

DOCUMENTATION NEEDED TO SUBMIT YOUR APPLICATION TO HOSPITALS

• Your application
• A copy of your Arizona or compact state nursing license
• * Copies of your certification cards (i.e. CPR, BLS, ACLS, NRP, NALS, PALS, etc.)
• * Work Experience Checklist
• Critical Care Skills Checklist
• * A signed release for your background and work/references checks
• Three references
• Three-year work history
• * Two evaluations completed by a co-worker in supervisory capacity, completed within the past six months

• * A physical exam completed within the past six months
• * Negative TB results, completed within the past six months (if you test positive for TB, a chest x-ray and TB questionnaire, completed within the past six months, are needed)
• * Proof of MMR (or rubella and rubeola titres/immunization)
• * Varicella titre
• * Hep B election form
• Drug test (information will be provided for you to go to Quest Diagnostics or Sonora Quest)
• * HIPAA statement
• * W4 and A4
• Direct deposit information
• * Proof of Professional Liability Insurance

(*)Items with an asterisk are required to get the application to the hospital.
All Items are required to confirm contract.

Seattle, WA 98117

First Name:
Middle Name:
Last Name:
E-Mail Address:
Password:
Re-enter Password:
Home Phone Number:
Cell Phone Number:
Fax Number:
Address
Street Address Line 1:
Street Address Line 2:
City:
State:		Armed Forces America Alberta Armed Forces Europe Alaska Alaska Alabama Alabama Armed Forces Pacific Arkansas American Samoa Arizona British Columbia California Colorado Connecticut District of Columbia Delaware Florida Federated States of Georgia Guam Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Massachusetts Manitoba Maryland Maine Maine Marshall Islands Michigan Minnesota Missouri Northern Mariana Isl Mississippi Montana New Brunswick North Carolina North Carolina North Dakota Nebraska Newfoundland New Hampshire New Jersey New Mexico Commonwealth of Nort Nova Scotia Northwest Territorie Nunavut Nevada New York New York Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Province of Quebec Puerto Rico Palau Quebec Rhode Island South Carolina South Carolina South Dakota Saskatchewan Tennessee Texas Utah Utah Virginia Virgin Islands Vermont Nunavut Territory (p Washington Washington Wisconsin West Virginia Wyoming Yukon Territory
Zip:
Start Date:		Birthday: 1 2 3 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31  /  January February March April May June July August September October November December  /
Preferred Shift Night/Day:		Night Day
Time Off Required:		Monday Tuesday Wednesday Thursday Friday Saturday Sunday