Nursing Applicant Information
Date:*    
Birthdate:
Month/Day
First Name:* MI
Last Name:*
SS#*
Legal Last Name:
Address:* Apt#
City:* State:*
Zip Code:*
Phone#*  
Cell#
Other#
Email:
How did you hear about us?*

Newspaper
 Friend
Internet
Yellowpages
Trade Publication
Job Fair/Event
Other
If other, please specify:
Are you currently a US citizen?
 Yes No
If No, What is your Country of residence?
Have you previously registered or interviewed with Lloyd in the past?
 Yes No
 
Nursing Information
What position are you applying for?*
 Travel Assignments
Per Diem
Local Contract
Full Time Employment
Other
If Per Diem, select Lloyd Healthcare office location:

Connecticut
Florida, Plantation
Florida, Tampa
Maryland
New Jersey
New York
 Pennsylvania
If Travel, indicate preferred assignment location(s):
If Other, please specify:
Cities/Counties:
Date of Availability:
How Many Hours a Week are You Willing to Work?*
Preferred Shifts:
Days
 Nights Weekends
Preferred Hours:
8 Hr. 12 Hr.
 
Specialty Experience (yrs.)
Years Category Certified
M/S Yes No
Telemetry Yes No
Critical Care Yes No
CCU Yes No
CVICU/Open Heart Yes No
MICU Yes No
NICU Yes No
PICU Yes No
SICU Yes No
PACU Yes No
Years Category Certified
Psych Yes No
ER Yes No
OR Yes No
Maternal Child Yes No
OB Yes No
Nursery Yes No
L&D Yes No
Dialysis Yes No
Long Term Care Yes No
Additional Experience:
 
Education
Institution:
Address:
City:
State:
Zip Code:
End Date:
Degree(s):
Please list your highest level degree(s)
 
Employment History (Please go back a min. of 3yrs.)
Please start with your most recent employer
Facility:
Address:
City:
State:
Zip Code:
 
Position:
Specialty:
   
Unit:
Dates From:
Dates To:
Report To:
Title:
Telephone#
Additional Report To:
Title:
Telephone#
Salary:


Reason For Leaving:
Assignment Type: Travel Assignment Per Diem Local Contract FTE

If travel, contract or per diem through an agency, please list agency name and address:
Agency Name: City: State:
Facility:
Address:
City:
State:
Zip Code:
 
Position:
Specialty:
   

Unit:
Dates From:
Dates To:
Report To:
Title:
Telephone#
Additional Report To:
Title:
Telephone#
Salary:   Reason For Leaving:
Assignment Type: Travel Assignment Per Diem Local Contract FTE

If travel, contract or per diem through an agency, please list agency name and address:
Agency Name: City: State:
Facility:
Address:
City:
State:
Zip Code:
 
Position:
Specialty:
   
Unit:
Dates From:
Dates To:
Report To:
Title:
Telephone#
Additional Report To:
Title:
Telephone#
Salary:   Reason For Leaving:
Assignment Type:

Travel Assignment Per Diem Local Contract FTE

If travel, contract or per diem through an agency, please list agency name and address:
Agency Name: City: State:
Facility:
Address:
City:
State:
Zip Code:
 
Position:
Specialty:
   
Unit:
Dates From:
Dates To:
Report To:
Title:
Telephone#
Additional Report To:
Title:
Telephone#
Salary:   Reason For Leaving:
Assignment Type:

Travel Assignment Per Diem Local Contact FTE

If travel, contact or per diem through an agency, please list agency name and address:
Agency Name: City: State:
Facility:
Address:
City:
State:
Zip Code:
 
Position:
Specialty:
   
Unit:
Dates From:
Dates To:
Report To:
Title:
Telephone#
Additional Report To:
Title:
Telephone#
Salary:   Reason For Leaving:
Assignment Type:

Travel Assignment Per Diem Local Contract FTE

If travel, contract or per diem through an agency, please list agency name and address:
Agency Name: City: State:
 
Credentials
License: RN LPN CNA
 
License/Cert#    
State
Exp Date:
License/Cert#
State
Exp Date:
License/Cert#    
State
Exp Date:
License/Cert#    
State
Exp Date:
License/Cert#    
State
Exp Date:
License/Cert#    
State
Exp Date:
License/Cert#    
State
Exp Date:
 
Malpractice Insurance:
Provider
Policy#
Coverage:
Exp Date:
BCLS:
Yes
No
Exp Date:
ACLS:
Yes
No
Exp Date:
PALS:
Yes
No
Exp Date:
NALS/NRP:
Yes
No
Exp Date:
Additional Coursework:
Physical Examination:

Yes
No
Exam Date:
PPD: Neg.
Pos.
Date:
If Positive: Chest X-Ray: Yes
No
Titer Results For:
 Varicella Mumps Rubella Rubeola
 
Has your professional license or certification ever been investigated or suspended?
 Yes No
Have you ever been convicted of a crime other than a minor traffic violation?
 Yes No
Have you ever been named as a defendant in a professional liability action?
 Yes No
 
Emergency Contact Information
In case of an emergency who can we contact?
Name:* Phone#*
 
I authorize you to verify my licenses, education, and other information included on my application and to supply that information to clients. I authorize Lloyd Staffing to forward all or any of my health screening and drug test results and other medical information, if any, maintained in Lloyd’s file or records with respect to me to any client of Lloyd in order to assist such client with evaluating me or making any decision regarding my assignment to such client. I release Lloyd Staffing from any liability it might otherwise have for forwarding this information. I authorize you and all former employers, given by me as references, to answer all questions and to give all information in connection with this application or in any way concerning me. I agree, if employed by you, that if I ever make claims against you for personal injuries, on your request I shall submit to examinations by physicians of your selection. I understand that my employment is at will or may be terminated by you at any time for any reason or no reason and upon termination by you it shall be without liability to me except for wages as have been earned by me as of the date of such termination. I understand that if accepted for employment, I will be working for Lloyd Staffing on its payroll, at its client's premises or other approved site. My employment, and each assignment to a client is at will. I understand that any information I learn while working for a client is to be kept confidential. It is agreed that I will obtain your permission before discussing or accepting permanent employment with a Lloyd Staffing Client. I agree to immediately notify Lloyd Staffing at the conclusion of each assignment or as soon as I become available. If I fail to give such notice, Lloyd Staffing may assume that I am not available for reassignment, and am not ready, willing and able to work. In consideration for my employment by Lloyd, I agree that during any assignment by Lloyd and for a period of 180 days following the completion of my last assignment through Lloyd, I will not (1) accept employment by, or perform services for any client of Lloyd to whom I have been assigned by Lloyd, without the prior written consent of Lloyd, or (2) accept any temporary assignment while on the payroll of any other staffing company at any such client, without the prior written consent of Lloyd. In consideration for my assignment to Lloyd clients, I agree that I am solely an employee of Lloyd for benefits plan purposes and that I am not eligible for or entitled to benefits provided by clients to any of their direct employees, regardless of the length of my assignment to clients by Lloyd and regardless of whether I am found to be a common law employee of Lloyd clients for any purpose. Therefore, with full knowledge and understanding, I hereby expressly waive any claim or right that I may have to such benefits and agree not to make any claim for such benefits. I state that the information provided on this application is true and complete. I understand that it shall be grounds to deny my application for immediate dismissal without notice if any of the information contained herein or in a pre-employment interview or resume is false, incomplete or misleading. I will hold Lloyd Staffing harmless from any claims including, but not limited to, personal injury or illness as a result of my providing false or misleading information on this application.

BY FILLING OUT THIS APPLICATION, YOU AGREE TO THE ABOVE TERMS.