* = Required Field!
 
Date Available
for Work *		 MM/DD/YY
First Name * Middle Initial Last Name *
Current Address *
City *      State *      Zip *
Address #2
(If you possess a PO Box for your main address, please provide another non-PO Box address.)
City      State      Zip
Email Address
Current Phone Number * Other Phone Number Cell Other
Social Security Number
Can you provide proof of eligibility to work in the United States? * Yes    No
Emergency Contact Phone Number
Emergency Contact (not living with you) Phone Number
Type of Degree:* RN   LPN/LVN CNA
Other (please specify below) 		Shift Preference:* AM      
PM      
Either
How did you hear about us?
EDUCATION
Name and Locations of School(s) Graduated Date

Type of Degree
* * *
LICENSURE
(Please list all including expired)
Professional License/
Technical Certificate		 # *

State *

# State
# State
# State
Which of these licenses is your original state of licensure? *
Has your license or certification ever been under investigation? *Yes    No
If YES, please explain
Has your license or certification ever been revoked or under suspension? * Yes    No
If YES, please explain
Resuscitation
Credential 		Expiration
Date
ACLS
BLS
ENPC
NRP
PALS
TNCC

PROFESSIONAL EDUCATION
Course Name Date CEUs Earned
ADDITIONAL INFORMATION
Have you ever been convicted of a felony that would prohibit your employment at a health care facility? * Yes    No
Have you ever been convicted of a felony in the past five years? * Yes    No
Are you currently employed? * Yes    No
Do you have any physical or mental conditions that would inhibit or restrict your ability to perform the essential functions of your job? * Yes    No
If YES, what are they?
Do you have one year of acute care experience in the past two (2) years? * Yes    No
Are you restricted in any way at any facilities? * Yes    No
If YES please explain
PLEASE CHECK ALL THAT APPLY:

I would like to be considered for travel positions with Champion.
Date available for assignment

I would like to be considered for local positions with Champion.
City/Cities Desired Locations:

EMPLOYMENT EXPERIENCE
Begin with your current or last job.
Provide, in chronological order, three (3) years of continuous employment.
Include any gaps of employment with a brief description.
Employer * Phone
Address
City *     State *      Zip
Supervisor May this person be contacted for a reference? Yes    No
Job Title * Specialty/Unit *
Employment Dates From *   To *  (MM/DD/YY) Full Time     Part Time
Supervisory Experience? Yes    No Reason for Leaving *
Comment:
Employer Phone
Address
City      State      Zip
Supervisor May this person be contacted for a reference? Yes    No
Job Title Specialty/Unit
Employment Dates From   To   (MM/DD/YY) Full Time     Part Time
Supervisory Experience? Yes    No Reason for Leaving
Comment:
Employer Phone
Address
City      State      Zip
Supervisor May this person be contacted for a reference? Yes    No
Job Title Specialty/Unit
Employment Dates From   To   (MM/DD/YY) Full Time     Part Time
Supervisory Experience? Yes    No Reason for Leaving
Comment:
Employer Phone
Address
City      State      Zip
Supervisor May this person be contacted for a reference? Yes    No
Job Title Specialty/Unit
Employment Dates From   To   (MM/DD/YY) Full Time     Part Time
Supervisory Experience? Yes    No Reason for Leaving
Comment:
Employer Phone
Address
City      State      Zip
Supervisor May this person be contacted for a reference? Yes    No
Job Title Specialty/Unit
Employment Dates From   To   (MM/DD/YY) Full Time     Part Time
Supervisory Experience? Yes    No Reason for Leaving
Comment:
Employer Phone
Address
City      State      Zip
Supervisor May this person be contacted for a reference? Yes    No
Job Title Specialty/Unit
Employment Dates From   To   (MM/DD/YY) Full Time     Part Time
Supervisory Experience? Yes    No Reason for Leaving
Comment:
PRIMARY APPLICANT AGREEMENT
Please be certain to read and sign the Primary Application Agreement.

I hereby certify the information contained in this application form is true and correct to the best of my knowledge, and I agree to have any of the statements checked by Champion Medical Staffing unless I have indicated so to the contrary. I authorize any and all former employees to release all employment records, reports, and other information related to my term of employment, including health records, requested by Champion Medical Staffing. Further, I release all parties and persons from any and all liability for any damages that may result from funishing such information to Champion Medical Staffing, as well as from the use or disclosure of such information by Champion Medical Staffing or any of its agents, employees, assigns, or representatives. I understand that any misrepresentation, flasification, or material omission of information on this application may result in my failure to receive an offer of employment: or, if I am hired, will result in my dismissal from employment with Champion Medical Staffing regardless the time elapsed before recovery.

For Corporation: For Applicant:

Champion Medical Staffing
1819 S Dobson Rd. Ste 203
Mesa, Arizona 85202

1-866-8CHAMPS
(480) 839-8800 Office
(480) 839-8811 Fax
Applicant Name:*
Applicant Address:*
Applicant Signature: ELECTRONIC SIGNATURE BELOW
NURSE ASSOCIATE PROFESSIONAL CONDUCT EXPECTATIONS
Your professional conduct and clinical performance on Champion assignments is directly related to our ability to solicit new and interesting job opportunities for you. Toward that end we expect that you will adhere to the following Professional Conduct Expectations while on assignment for Champion. Failure to meet these expectations could lead to your termination from the company.
  • I will not discuss any elements of my compensation with anyone employed at the host facility.
  • I will not discuss any previous assignment worked for Champion with anyone employed at the host facility.
  • I will not recruit any nurses at the host facility, whether temporary or permanent employees.
  • I will communicate with the management, staff and patients of the host facility in a respectful manner at all times.
  • I will honor all terms of the primary applicant agreement.
  • I will honor the policies and procedures of Champion and the host facility.

I certify that I have read, understand and intend to comply with the Primary Applicant Agreement and Professional Conduct Expectations and that the facts contained in this application are true and accurate. I understand that any misrepresentation or omission of facts is cause for dismissal. I authorize the employer to investigate any and all statements contained herein and request the persons, firms, and/or corporations named above to answer any and all questions relating to this application. I release all parties from liability, including but not limited to, the employer and any person, firm or corporation who provides information concerning my prior education, employment or character.


PLEASE NOTE:
BEFORE SUBMITTING THIS APPLICATION, YOU MUST AGREE TO THE FOLLOWING TERMS AND CONDITIONS.


I attest that the information provided in this application is complete and accurate, to the best of my knowledge. Providing incomplete or inaccurate information may result in disqualification from possible employment with Champion Medical Staffing and may be a violation of state law(s) that could result in civil penalties. Champion Medical Staffing is authorized to obtain information from my current and previous employers, and to release information in support of my application (application, references, background search results, etc.) to client institutions and to appropriate governmental or licensing entities. Champion Medical Staffing may also share applicant information with its affiliates. I understand that Champion Medical Staffing, certain states and/or client institutions may require criminal background checks, and I consent to such checks. Prior to conducting any background checks that qualify as consumer or investigative consumer reports, I will be provided and will return, separate disclosure and acknowledgement forms as required by Champion Medical Staffing

Electronic Signature Statement: I acknowledge that inserting my personal information above represents my signature.

Name of Applicant *

    
Signature of Applicant *
(type full name)		 Signature Date *

 
Copyright © Champion Medical Staffing 2007 All rights reserved 1819 S. Dobson Rd. Ste 203 | Mesa, Arizona 85202 | 1-866-8CHAMPS