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You’re 15 minutes closer to your next travel assignment! To the best of your knowledge, please accurately complete the application below.

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First Name, Last Name
Permanent Address
Temporary Address (if applicable)
E-mail Address
Home Phone
Cell Phone
Preferred Form of Communication (check all that apply)
Overall Acute Care Experience
State of Licensure (check all that apply)
Alabama Illinois Montana Rhode Island
Alaska Indiana Nebraska South Carolina
Arizona Iowa Nevada South Dakota
Arkansas Kansas New Hampshire Tennessee
California Kentucky New Jersey Texas
Colorado Louisiana New Mexico Utah
Connecticut Maine New York Vermont
Delaware Maryland North Carolina Virginia
District Of Columbia Massachusetts

North Dakota

Washington

Florida Michigan Ohio West Virginia
Georgia Minnesota Oklahoma Wisconsin
Hawaii Mississippi Oregon Wyoming
Idaho Missouri Pennsylvania    
Where would you like to travel? (check all that apply)
Alabama Illinois Montana Rhode Island
Alaska Indiana Nebraska South Carolina
Arizona Iowa Nevada South Dakota
Arkansas Kansas New Hampshire Tennessee
California Kentucky New Jersey Texas
Colorado Louisiana New Mexico Utah
Connecticut Maine New York Vermont
Delaware Maryland North Carolina Virginia
District Of Columbia Massachusetts

North Dakota

Washington

Florida Michigan Ohio West Virginia
Georgia Minnesota Oklahoma Wisconsin
Hawaii Mississippi Oregon Wyoming
Idaho Missouri Pennsylvania    
In the boxes below, please check the specialties you are interested and qualified to work in and then list
how many years of experience you have in each corresponding specialty:
Cardiology Oncology
Cath Lab Operating Room
CCU Orthopedics
CVICU PACU
CVOR Pediatrics
Detox PICU
Dialysis Psych
Emergency Room Recovery Room
Geriatric Rehab
ICU SICU
L&D Stepdown
Med/Surg Telemetry
Mother/Baby Other
NICU
Please check all certifications you have with expiration dates.

CERTIFICATION     EXPIRATION DATE
ACLS
BCLS
CCRN
CEN
Chemo
CNRN
CVOR
ENA
ENPC
FHM
NRP
PALS
TNCC
Have you worked as a travel nurse before?
Yes No
If yes, when and where was your last travel position?
Date available for next assignment?
Preferred shifts (check all that apply)
Day
Eve
NOC
12 Hr Day
12 Hr NOC
With 1 being the most important and 10 being the least important, please rank the most important attributes in choosing a travel company/assignment?
401k
Health Insurance
Hourly Pay
Location
Private Housing and/or Reimbursement
Relationship with My Recruiter
Shift Preference Availability
Start Date
Travel Company Reputation
Other
Please describe in detail what your ideal travel assignment would look like?
Are you a U.S. Citizen or can you submit verification of your legal right to work in the U.S.?
Yes No
Have you ever been disciplined by professional state ethics or licensing board?
Yes No
If yes, gives dates and explanation (where, when, etc.):
Have you ever been convicted of a crime other than a minor traffic violation?

A conviction, guilty plea or no contest will not necessarily disqualify you for employment consideration. However, failure to provide complete and truthful information may disqualify you from being hired or may result in termination if discovered after employment has commenced. A satisfactory criminal background check may be a condition of employment. I understand that each respective company may require a criminal background check and I will provide my authorization to release such information via a signed form as required by each respective company prior to this being performed.
Yes No
If yes, please explain:
How did you hear about us?
Addition Comments:
By submitting my application, I hereby attest that I am the applicant and certify that the information provided is accurate and complete to the best of my knowledge. I further understand that misrepresentation or omission of information in connection with my application and interview will be sufficient cause, in and of itself, for rejection or dismissal whenever discovered and may be a violation of state law(s) that could result in civil penalties. I consent and expressly authorize to have Vita Teres Travel share my information for potential employment opportunities with its travel nurse agency partners. I further understand that I may be contacted and receive employment related information at the contact information provided above. Finally, Vita Teres Travel shall not be responsible nor held liable for any employment based decisions as these will be determined solely by the applicant and each respective travel nurse company.
 
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