Submit Your Application

Personal Information - * Red Asterisks are required fields *
Last Name *		First Name *
Middle Name:		Current Street Address or P.O. Box:
Current City:*		Current State:*	Please select your state.
Current Zip:		Home Phone:
Cell Phone:*		Voicemail:
Social Security #:		Email Adress:*
Permanent Street Address or P.O. Box:		Permanent City:
Emergency Contact Name: *		Permanent Zip:
Emergency Contact Number:*
Are you legally authorized to work in the United States?*	Yes No Please make a selection.	Will you be employed on a VISA?*	Yes No Please make a selection.
If yes, please specify which type of VISA:		Have you ever been convicted of a felony?*	Yes No Please make a selection.
Has your professional license / cert. ever been investigated or suspended?*	Yes No Please make a selection.	Driver's License State: Number: Expires	Please select your state.
Alien Registration / Permanent Resident card Number:		How did you hear about us?*
Name of your AAMS recruiter:*	Please select your Recruiter.
Education Information
Name & Address of College / University / School of Nursing:
Year Graduated:		Degree Obtained:
Name & Address of College / University / School of Nursing:
Year Graduated:		Degree Obtained:
Name & Address of College / University / School of Nursing:
Year Graduated:		Degree Obtained:
Professional License / Technical Certification (Please include all, including expired)
1. State: License Number: Expiration Date:	Example 03/22/2014	2. State: License Number: Expiration Date:	Example 03/22/2014
3. State: License Number: Expiration Date:	Example 03/22/2014	4. State: License Number: Expiration Date:	Example 03/22/2014
5. State: License Number: Expiration Date:	Example 03/22/2014	6. State: License Number: Expiration Date:	Example 03/22/2014
What is your original state of licensure?		Have you obtained licensure / certification under another name?*	Yes No
What other name have you used? * (Required if you answered yes above)
Employment Experience
Employed From:*		Employed To:*
Employer Name:*		Street Address:
City:*		State:*	Please select your state.
Zip:		Supervisor's Name:*
Supervisor's Title:*		Supervisor's Telephone Numbers:
Position Held:*		Specialty / Unit:*
Shift*		Reason for Leaving*
Was this a Travel Assignement?		Agency Name
Previous Job 2
Employed From:		Employed To:
Employer Name:		Street Address:
City:		State:
Zip:		Supervisor's Name:
Supervisor's Title:		Supervisor's Telephone Numbers:
Position Held:		Specialty / Unit:
Shift		Reason for Leaving
Was this a Travel Assignement?		Agency Name
Previous Job 3
Employed From:		Employed To:
Employer Name:		Street Address:
City:		State:
Zip:		Supervisor's Name:
Supervisor's Title:		Supervisor's Telephone Numbers:
Position Held:		Specialty / Unit:
Shift		Reason for Leaving
Was this a Travel Assignement?		Agency Name
Previous Job 4
Employed From:		Employed To:
Employer Name:		Street Address:
City:		State:
Zip:		Supervisor's Name:
Supervisor's Title:		Supervisor's Telephone Numbers:
Position Held:		Specialty / Unit:
Shift		Reason for Leaving
Was this a Travel Assignement?		Agency Name
Previous Job 5
Employed From:		Employed To:
Employer Name:		Street Address:
City:		State:
Zip:		Supervisor's Name:
Supervisor's Title:		Supervisor's Telephone Numbers:
Position Held:		Specialty / Unit:
Shift		Reason for Leaving
Was this a Travel Assignement?		Agency Name
Previous Job 6
Employed From:		Employed To:
Employer Name:		Street Address:
City:		State:
Zip:		Supervisor's Name:
Supervisor's Title:		Supervisor's Telephone Numbers:
Position Held:		Specialty / Unit:
Shift		Reason for Leaving
Was this a Travel Assignement?		Agency Name
Previous Job 7
Employed From:		Employed To:
Employer Name:		Street Address:
City:		State:
Zip:		Supervisor's Name:
Supervisor's Title:		Supervisor's Telephone Numbers:
Position Held:		Specialty / Unit:
Shift		Reason for Leaving
Was this a Travel Assignement?		Agency Name
Previous Job 8
Employed From:		Employed To:
Employer Name:		Street Address:
City:		State:
Zip:		Supervisor's Name:
Supervisor's Title:		Supervisor's Telephone Numbers:
Position Held:		Specialty / Unit:
Shift		Reason for Leaving
Was this a Travel Assignement?		Agency Name
Previous Job 9
Employed From:		Employed To:
Employer Name:		Street Address:
City:		State:
Zip:		Supervisor's Name:
Supervisor's Title:		Supervisor's Telephone Numbers:
Position Held:		Specialty / Unit:
Shift		Reason for Leaving
Was this a Travel Assignement?		Agency Name
Previous Job 10
Employed From:		Employed To:
Employer Name:		Street Address:
City:		State:
Zip:		Supervisor's Name:
Supervisor's Title:		Supervisor's Telephone Numbers:
Position Held:		Specialty / Unit:
Shift		Reason for Leaving
Was this a Travel Assignement?		Agency Name

Neonatal Intensive Care		Pediatirc Intensive Care
Medical Surgical		Telemetry / Intermediate Care
Emergency Room		Operating Room
Psychiatric		Critical Care
Pediatric		Labor and Delivery, Postpartum and Nursery

1) Review Your Application
Carefully review the information above and be sure everything you entered is correct.
2) Add Additional Comments
Enter any additional comments or information in the space provided below. Please limit your comments to 10 lines. IF YOUR COMMENTS DO NOT APPEAR IN THE BOX BELOW IT WILL NOT BE SENT. If you would like to send a resume, please email it to info@acrossamer.com

3) Submit your Application
When you are ready to submit your application, click on the button below. By clicking "Submit My Application" you confirm that you have read and agree to the following statement: I understand that my employment is "at will: and may be terminated by AAMS or me at any time, with or without prior notice, for any lawful reason or no reason. I further understand no contracts is intended by me or AAMS and as such my omployment is not governed by any contractual realtionship with AAMS. I certify 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 authorise the employer to investigate any and all statements contained herein and request the presons, firms, and/or coprorations names above to anser any and all questions relating to the application. I release all parties from all liability, including but not limited to, the employer and any person, firm, or corporation who provides information concerning my prior education, employment or charcter.
	It may take a few seconds (30 or more) to submit your application. Please be patient. Upon successful submittal, a thank you page will be displayed.

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