Email Surgistaff

SF Bay Area:
t: (415) 332-4006

Outside Areas:
t: (707) 265-9180
f: (707) 265-9182
toll free: (800) 603-6664

Surgistaff, Medical Division

Traveler/Contract Application

Personal Information

Please enter your name:

Email:

Home Phone:

Work Phone:

Professional discipline:

Specialties:

Years in current profession?

Years in current specialty?

Dates available to travel:

Current Address:

Permanent Address:

At this location until:

Licensure and Certifications

State:

Expiration:

State:

Expiration:

State:

Expiration:

Certified

Registered

CPR

ACLS

Other

Certification Info:

Expiration:

Are you a US Citizen?

Do you have a legal right to work in the US?

Has your professional license or certification ever been investigated or suspended?

If yes, please give details and current status:

Have you ever been convicted of a crime other than a minor traffic violation?

If yes, please give details and current status:

Have you ever been named as a defendant in a professional liability action?

Education

College Name:

City/State:

Diplomas/Degrees Received:

Graduation Date:

College Name:

City/State:

Diplomas/Degrees Received:

Graduation Date:

College Name:

City/State:

Diplomas/Degrees Received:

Graduation Date:

Emergency Contact

Name of emergency contact:

Relationship:

Phone:

Street Address:

City:

State:

Zip code:

Employment History

Please indicate all of your employment for the past ten (10) years, beginning with your most recent employer. Please list each facility in which you have worked.

Are you employed now?

If so, may we contact your employer?

Other names under which you have been employed:

Facility/Employer:

Department:

Street Address:

City:

State:

Zip:

Dates Employed:

Reason for leaving:

Position held:

Supervisor's name/title:

Supervisor's Phone:

Other Supervisor:

Other Supervisor Phone:

Travel Assignment?

Local staff agency?

Facility/Employer:

Department:

Street Address:

City:

State:

Zip:

Dates Employed:

Reason for leaving:

Position held:

Supervisor's name/title:

Supervisor's Phone:

Other Supervisor:

Other Supervisor Phone:

Travel Assignment?

Local staff agency?

Facility/Employer:

Department:

Street Address:

City:

State:

Zip:

Dates Employed:

Reason for leaving:

Position held:

Supervisor's name/title:

Supervisor's Phone:

Other Supervisor:

Other Supervisor Phone:

Travel Assignment?

Local staff agency?

I attest that the information provided within this application represents a full and complete disclosure of information about my current and previous employers, and is true and correct to the best of my knowledge and belief. I understand and acknowledge that failure to provide a full and complete disclosure of my employment information is a violation of the law, and could result in civil penalties. I acknowledge that any misstatement or omission of fact on this application may result in my disqualification from employment with SurgiStaff, division of HiTech Searches, Inc. I authorize a full release for SurgiStaff to obtain information from my current and previous employers. I authorized SurgiStaff to release this application and reference information to SurgiStaff affiliates, and SurgiStaff Client institutions, only after receiving my express written or verbal consent for each assignment opportunity. I understand that by giving SurgiStaff permission to submit my application for assignment opportunities, I am also agreeing to background searches that may be required by SurgiStaff, certain states or Client institutions. Prior to conducting any background searches that qualify as "consumer" or "investigative consumer" reports, applicant will be provided separate disclosure and acknowledgement forms.

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