Refer­ral Source: How were you referred to us?

Google Indeed Ask.com DET News­Pa­per Yahoo MSN Other

Con­tact Infor­ma­tion

*Last Name	*First Name	*Mid­dle Name
*Address
*City	*State	*Zip Code
*Home Phone	*Cell Phone
Do you have MSG’s Recruiter? Yes No    If yes, list Recruiter’s name:
*Email Address Social Secu­rity # (Vol­un­tary) Type of posi­tion apply­ing for (cir­cle all that apply): 4 wk 8 wk 13 wk Per Diem Other Shift Pre­ferred: Day Night Other Emer­gency Con­tact (not spouse): Phone: Pri­mary Lan­guage: Sec­ond Lan­guage: Other Lan­guage:

Edu­ca­tion Infor­ma­tion

Name of School	Attended From / To	Grad­u­ated?	Degree / Title	Major / Subjects
H.S.		Yes No
Col­lege or Uni­ver­sity		Yes No
Other		Yes No

Pro­fes­sional References:

Please list three indi­vid­u­als who have knowl­edge of your work, per­sonal abil­i­ties and char­ac­ter. (No For­mer Employ­ers or Rel­a­tives)

Name	Title /	Known how long?	Home Phone	Work Phone	Per­mis­sion to call?
					Yes No
					Yes No
					Yes No

Licen­sure Infor­ma­tion

State	Expi­ra­tion Date	State	Expi­ra­tion Date
1. MA License #:		2. Other State License:

Cer­ti­fi­ca­tion Infor­ma­tion (Please include a copy of each)

Type	Type	Type	Nurs­ing Skill Check­list to be Completed
BCLS/CPR	CEN	ENCP	MED-SURG	OR	PEDIACTRIC	CASE MANAGER
PALS	CNOR	TNCC	ER	L & D	HOSPICE	TELEMETRY
ACLS	CCRN	Other:	ICU/CCU	PICU	ONCOLOGY	ENDOSCOPY
NALS/ NRP	CHEMO	Other:	DIALYSIS	PACU	ONCOLOGY	ENDOSCOPY

Work Expe­ri­ence

Employer		City		State
From	To	Present	Title	Salary Annual Hourly
Descrip­tion of duties:
Imme­di­ate Supervisor:				Phone:	May We Con­tact? Yes No
Rea­son for Leaving:

Add New Work Experience:

Employer		City		State
From	To	Present	Title	Salary Annual Hourly
Descrip­tion of duties:
Imme­di­ate Supervisor:				Phone:	May We Con­tact? Yes No
Rea­son for Leaving:

Employer		City		State
From	To	Present	Title	Salary Annual Hourly
Descrip­tion of duties:
Imme­di­ate Supervisor:				Phone:	May We Con­tact? Yes No
Rea­son for Leaving:

Employer		City		State
From	To	Present	Title	Salary Annual Hourly
Descrip­tion of duties:
Imme­di­ate Supervisor:				Phone:	May We Con­tact? Yes No
Rea­son for Leaving:

Ref­er­ence Check 1

Appli­cant Name		Posi­tion Held
Current/Former Employer		Phone #	Dates of Employ­ment
Com­plete Mail­ing Address	City	State	Zip
I hereby give per­mis­sion to the above named employer to release infor­ma­tion to Med­ical Staffing Group, Inc. regard­ing my per­for­mance while employed at this facil­ity.
Applicant’s Sig­na­ture		Date

Employer

The per­son above is reg­is­tered with Med­ical Staffing Group and has listed you as a pre­vi­ous employer. We would appre­ci­ate your assis­tance in ver­i­fy­ing employ­ment and eval­u­at­ing job per­for­mance. All infor­ma­tion is con­fi­den­tial.
Is this employee eli­gi­ble for rehire? Yes No

Per­sonal Evaluation	Above Aver­age	Sat­is­fac­tory	Unsat­is­fac­tory
Clin­i­cal Competency
Qual­ity of Work
Quan­tity of Work
Atti­tude
Team Work
Depend­abil­ity
Atten­dance and Punctuality

Comments:
Employer’s Sig­na­ture	Date

Yes
I am inter­ested in find­ing out how Med­ical Staffing Group, Inc can help staff my facil­ity. Please send infor­ma­tion regard­ing Med­ical Staffing Group, Inc com­pre­hen­sive list of services.
Name	Tel	Fax
Title	Email

Ref­er­ence Check 2

Appli­cant Name		Posi­tion Held
Current/Former Employer		Phone #	Dates of Employ­ment
Com­plete Mail­ing Address	City	State	Zip
I hereby give per­mis­sion to the above named employer to release infor­ma­tion to Med­ical Staffing Group, Inc. regard­ing my per­for­mance while employed at this facil­ity.
Applicant’s Sig­na­ture		Date

Employer

The per­son above is reg­is­tered with Med­ical Staffing Group and has listed you as a pre­vi­ous employer. We would appre­ci­ate your assis­tance in ver­i­fy­ing employ­ment and eval­u­at­ing job per­for­mance. All infor­ma­tion is con­fi­den­tial.
Is this employee eli­gi­ble for rehire? Yes No

Per­sonal Evaluation	Above Aver­age	Sat­is­fac­tory	Unsat­is­fac­tory
Clin­i­cal Competency
Qual­ity of Work
Quan­tity of Work
Atti­tude
Team Work
Depend­abil­ity
Atten­dance and Punctuality

Comments:
Employer’s Sig­na­ture	Date

Yes
I am inter­ested in find­ing out how Med­ical Staffing Group, Inc can help staff my facil­ity. Please send infor­ma­tion regard­ing Med­ical Staffing Group, Inc com­pre­hen­sive list of services.
Name	Tel	Fax
Title	Email

Visa Infor­ma­tion

Please note that as required by the immi­gra­tion reform and con­trol act of 1986, you can­not be employed unless you can pro­duce work autho­riza­tion and iden­tity doc­u­ments as spec­i­fied by the law. If you can­not pro­vide proper doc­u­men­ta­tion, you should dis­cuss this with your recruiter immediately.

Yes No

Have you ever had dis­ci­pli­nary action taken against your license? Yes No If yes, please explain: Do you accept as a con­di­tion of employ­ment, you may be required to take and pass a drug and/or alco­hol screen where per­mit­ted by applic­a­ble law under cir­cum­stances such as pre-employment where required by our CLIENTS or for the nature of the ser­vices pro­vided; after acci­dents caus­ing injury; and as legally per­mit­ted or nec­es­sary for the ren­der­ing of health care ser­vices. Yes No If yes, please explain: Do you have any com­mit­ments to another employer that might affect your employ­ment? Yes No Does your present employer know you are con­sid­er­ing leav­ing? Yes No Are there any employ­ers who might not rehire you? Yes No If yes, please explain:

Autho­riza­tion

                                 I hereby cer­tify that the infor­ma­tion sub­mit­ted on this appli­ca­tion is accu­rate. I under­stand that this appli­ca­tion is not a con­tract for employ­ment with MSG for either employ­ment or for pro­vid­ing of any ben­e­fit. Any offers of employ­ment are made con­di­tional upon the ver­i­fi­ca­tion of infor­ma­tion pro­vided though this appli­ca­tion and a sup­ple­men­tal inquiry. I under­stand that any fal­si­fi­ca­tion on this ini­tial or sup­ple­men­tal appli­ca­tion will result in dis­qual­i­fi­ca­tion for employ­ment or ter­mi­na­tion of ser­vices. I under­stand that as a require­ment of employ­ment with MSG, ver­i­fi­ca­tion of edu­ca­tion, includ­ing any degrees or cer­ti­fi­ca­tion pro­grams and state licen­sure as well as crim­i­nal back­ground screen are required for all appli­cants to MSG. I hereby autho­rize all pre­vi­ous edu­ca­tional insti­tu­tions, cer­ti­fi­ca­tion pro­grams, and state licens­ing facil­i­ties to release my infor­ma­tion to MSG. I under­stand that some client facil­i­ties may require drug screen­ing and that my Recruit­ment Spe­cial­ist will inform me of these require­ments before I accept an assign­ment at one of these facil­i­ties. I hereby autho­rize my cur­rent and pre­vi­ous employ­ers to release infor­ma­tion regard­ing my work per­for­mance to MSG. Upon ter­mi­na­tion, I autho­rize the release of ref­er­ence infor­ma­tion regard­ing my work per­for­mance. I release all such employ­ers from any lia­bil­ity for issu­ing this infor­ma­tion to MSG. I under­stand and agree that if I am offered employ­ment by MSG, it will be on an at-will basis. This means that either MSG or I may ter­mi­nate the employ­ment rela­tion­ship at any time, for any rea­son, with or with­out cause or notice. I under­stand MSG is a tem­po­rary agency, and as such MSG can­not promise the avail­abil­ity of requested work unless dif­fer­ent con­tract signed. I agree to con­form to all rules and reg­u­la­tions of MSG as they presently exist or are later mod­i­fied.

                                  I under­stand that I am not required to pro­vide my social secu­rity num­ber. I under­stand that if I choose to pro­vide my social secu­rity num­ber, it will be used in con­nec­tion with the back­ground checks described above, includ­ing ver­i­fi­ca­tion of my state licen­sure. I autho­rize MSG to release any employ­ment records, includ­ing health records and my social secu­rity num­ber (if pro­vided) sub­mit­ted to MSG to any client of MSG for con­sid­er­a­tion of employ­ment at cus­tomer facil­ity. I under­stand that MSG is not respon­si­ble for any actions or omis­sions of its clients, includ­ing with­out lim­i­ta­tion any mis­use of my per­sonal infor­ma­tion by such clients, or any fail­ure by such clients to pro­tect and keep con­fi­den­tial my per­sonal infor­ma­tion. I hereby release MSG from any and all lia­bil­ity aris­ing out of such clients’ use or pos­ses­sion of my per­sonal infor­ma­tion.

Signature

Date

I agree I do not agree to these terms

                                 Med­ical Staffing Group is com­mit­ted to respect­ful and equal treat­ment for all employ­ees. This com­mit­ment includes non-discrimination towards appli­cants and employ­ees on the grounds of race, color, creed, reli­gion, age, sex, dis­abil­ity, national ori­gin, ances­try, sex­ual ori­en­ta­tion, mar­i­tal sta­tus, or with regard to pub­lic assis­tance, or union or non-union sta­tus. This pre­vails through­out the employ­ment rela­tion­ship, includ­ing, but not lim­ited to recruit­ment, selec­tion, train­ing, trans­fer, com­pen­sa­tion, pro­mo­tion, demo­tion, lay­off and ter­mi­na­tion.