Welcome to STAT Staffing, Accredited and Certified Since 1987
[ABOUT STAT] [JOB SEEKERS] [EMPLOYERS]

STAT Staffing, Inc. – Full Employment Application
[Click Here For The Quick Application]
Required fields are indicated by "•"
• First Name:
Middle Name: 
• Last Name:
Social Security #:
• Street Address/ P.O. Box:
• City:
• State:
• Zip:
• Home Phone:
Cell Phone:
Fax:
Pager:
E-mail Address:
Emergency Contact Name:
Emergency Contact Address:
Emergency Contact Phone:
Driver's License State:
Driver's License Number:
Driver's License Expires: (mm/dd/yyyy)
• Are you legally authorized to work in the United States? Yes No
Who can we thank for your referral?
• Have you ever applied to or been employed by STAT Staffing, Inc.? Yes No
• Have you ever been convicted of any misdemeanor or felony within the last 7 years? Yes No
• Check As Appropriate:
(Certification)		 CNA
LPN
RN
PT
PTA
SLP
OT
COTA
CHHA
OTHER
Type of Employment Desired: Travel (13-26 weeks)
Per Diem
Direct Placement
Fast Response (4 week only)
Type of Shifts: 8 Hour Shifts
12 Hour Shifts
10 Hour Shifts
Other
Shift Preference: DAY
NOC
EVE
 
 
• Please select, from the following, the skill/unit in which you have one year experience in the past 24 months as primary care:
ER
ICU
OBGYN
OR
PICU
TELE
PEDS
L & D
MS
PACU
PSYCH
THERAPY
PRIV DUTY
SCHOOL
SNF
OTHER


Professional Licensure/Certification
1. State:
License Number:
Expiration date: (mm/dd/yyyy)
2. State:
License Number:
Expiration date: (mm/dd/yyyy)
3. State:
License Number:
Expiration date: (mm/dd/yyyy)
  Expiration Date
CPR/BLS (mm/dd/yyyy)
ACLS (mm/dd/yyyy)
NALS/NRP (mm/dd/yyyy)
PALS (mm/dd/yyyy)
IV CERT (mm/dd/yyyy)
CCRN (mm/dd/yyyy)
TNCC (mm/dd/yyyy)
 

Employment History
Clinical positions most recent first
1. Employed from:
 (mm/dd/yyyy)
Employed to:
 (mm/dd/yyyy)
Facility:
Street Address:
City:
State:
Zip:
Facility Supervisor's Name:
Facility Supervisor's Title:
Facility Supervisor's Telephone Number:
Your Title:
Unit Assigned:
Number of Beds:
Was this a travel assignment?
 Employee
Travel Assignment
Reason for Leaving:
Agency name:
Area/Unit
Worked
% of the
time
In what
capacity?
 
2. Employed from:
 (mm/dd/yyyy)
Employed to:
 (mm/dd/yyyy)
Facility:
Street Address:
City:
State:
Zip:
Facility Supervisor's Name:
Facility Supervisor's Title:
Facility Supervisor's Telephone Number:
Your Title:
Unit Assigned:
Number of Beds:
Was this a travel assignment?
 Employee
Travel Assignment
Reason for Leaving:
Agency name:
Area/Unit
Worked
% of the
time
In what
capacity?
 
3. Employed from:
 (mm/dd/yyyy)
Employed to:
 (mm/dd/yyyy)
Facility:
Street Address:
City:
State:
Zip:
Facility Supervisor's Name:
Facility Supervisor's Title:
Facility Supervisor's Telephone Number:
Your Title:
Unit Assigned:
Number of Beds:
Was this a travel assignment?
 Employee
Travel Assignment
Reason for Leaving:
Agency name:
Area/Unit
Worked
% of the
time
In what
capacity?
 
 
Education Information
What is the highest clinical degree/certification received?
1. School Name, City & State:
Area of Concentration:
Year Graduated from School:
Degree Type:
2. School Name, City & State:
Area of Concentration:
Year Graduated from School: