Associate Medical

Where temporary work can be your permanent job!®

Applicants

Online Application for Employment

This form will take you through process of applying for employment. Fields marked with a * are required.

» Start Application «
» Basic Information «
» Employment Desired «
» Specific Experience «
» Referral Source «
» Education Information «
» License Information «
» Work Information «
» Employment History «
» General Availability «
» Restrictions «
» Current Availability «
» Email Information «
» Acceptance & Submitting «

Start Application (Step 1 / 14)

This form will take you through the online application process. Please start by filling in your social security number and clicking "Next."

* SSN

- -

Basic Information (Step 2 / 14)

Fill in the basic information about you listed below.

* First Name
Middle Name
* Last Name
* Address
* City
* State
* Zip Code
* Telephone	- -
Alternative Telephone	- -

Referral Source (Step 5 / 14)

Tell us how you heard about us.

How did you hear about Associate Medical?	Newspaper Phone Book Hospital Web Site Word of Mouth AMP Employee
Referring Employee Name

School Information (Step 6 / 14)

Please list any college, university, or tech school you have attended since high school. You must include information about your nursing diploma / degree.

Some facilities require that we verify your education. To do so this information must be accurate.

School 1

* Full name of School (no initials please)
* City
* State
* Completion Status	If completed, month and year of graduation / and name on diploma
List all certifications or degrees obtained from this school.

School 2

Full name of School (no initials please)
City
State
Completion Status	If completed, month and year of graduation / and name on diploma
List all certifications or degrees obtained from this school.

School 3

Full name of School (no initials please)
City
State
Completion Status	If completed, month and year of graduation / and name on diploma
List all certifications or degrees obtained from this school.

School 4

Full name of School (no initials please)
City
State
Completion Status	If completed, month and year of graduation / and name on diploma
List all certifications or degrees obtained from this school.

School 5

Full name of School (no initials please)
City
State
Completion Status	If completed, month and year of graduation / and name on diploma
List all certifications or degrees obtained from this school.

License Information (Step 7 / 14)

Fill in the following information regarding your Oklahoma license.

When did you pass the nursing boards?	, (Ex. January, 2000)
In what state did you take the test?
Current Oklahoma License Expiration	/ Temporary
Current Oklahoma License Certification Number
Current Oklahoma License Biennial Number
Have you ever been convicted of a felony?
Have you ever been or are you currently under disciplinary supervision by the State Board of Nursing?
Are you currently or have you ever been a defendant in a malpractice lawsuit or any lawsuit involving your nursing practice?

Work Information (Step 8 / 14)

Fill in the following information regarding your previous employment.

May we contact your present employer now?
...If not, when?
If employed under a different name, please list that name here.

Employment History (Step 9 / 14)

Please list all employments in nursing since you graduated or for the past seven years whichever is least. Be sure to include full time, part time and agency employment.

Employer 1

* Company Name
Job Title
Address
City
State
Zip Code
Telephone	- -
Areas Worked
Supervisor's Name
From	, (Ex. January, 2000)
To	, (Ex. January, 2000)
Final Salary	(Ex. 65000 Annual)
Charge Experience
Average Number of Hours per Week
Reason for Leaving (30 words max)

Employer 2

Company Name
Job Title
Address
City
State
Zip Code
Telephone	- -
Areas Worked
Supervisor's Name
From	, (Ex. January, 2000)
To	, (Ex. January, 2000)
Final Salary	(Ex. 65000 Annual)
Charge Experience
Average Number of Hours per Week
Reason for Leaving (30 words max)

Employer 3

Company Name
Job Title
Address
City
State
Zip Code
Telephone	- -
Areas Worked
Supervisor's Name
From	, (Ex. January, 2000)
To	, (Ex. January, 2000)
Final Salary	(Ex. 65000 Annual)
Charge Experience
Average Number of Hours per Week
Reason for Leaving (30 words max)

Employer 4

Company Name
Job Title
Address
City
State
Zip Code
Telephone	- -
Areas Worked
Supervisor's Name
From	, (Ex. January, 2000)
To	, (Ex. January, 2000)
Final Salary	(Ex. 65000 Annual)
Charge Experience
Average Number of Hours per Week
Reason for Leaving (30 words max)

Employer 5

Company Name
Job Title
Address
City
State
Zip Code
Telephone	- -
Areas Worked
Supervisor's Name
From	, (Ex. January, 2000)
To	, (Ex. January, 2000)
Final Salary	(Ex. 65000 Annual)
Charge Experience
Average Number of Hours per Week
Reason for Leaving (30 words max)

Restrictions (Step 11 / 14)

List any restrictions for your employment.

List any specific areas or facilities that you want your assignments restricted to.
(40 words max)

Current Availability (Step 12 / 14)

Answer the following information regarding when you be able to complete orientation and begin working.

When will you be able to begin assignments?
Do you work for other agencies?	No Yes If yes, specify:
Facilities oriented to or assigned to
Will you be available for orientation during the day on weekdays?	No Yes
List any special accommodations that might be required to complete orientation (40 words max)

Email Information (Step 13 / 14)

Please enter your email address

Acceptance & Sending (Step 14 / 14)

Read all the information below. If you agree, enter your name and social security number. Then click "Submit" to submit the application.

I certify that all of the information submitted by me on this application is true and complete, and I understand that if any false information, omissions, or misrepresentations are discovered, my application may be rejected and, if I am employed, I may be subject to discipline up to and including discharge. I agree that should my work verifications require Associate Medical Professionals to pay fees (i.e. calling 900 numbers, www.theworknumber.com, etc) to secure information, those fees will be deducted from any bonus for which I may qualify (orientation, sign on, referral, etc) at the time of my employment. I understand and agree that if I am hired by Associate Medical Professionals, assignments are not guaranteed and my employment with Associate Medical Professionals is at will. This means that just as I have the right to end my employment with Associate Medical Professionals at any time, for any reason, or no reason, with or without notice, Associate Medical Professionals has the right to end my employment with them at any time for any reason or no reason, with or without notice. I understand that no supervisor, manager, or representative of Associate Medical Professionals other that its President, and then only in writing and signed by the President, has any authority to enter into any agreement with an employee for employment for any specific period of time, or to make any agreement contrary to the foregoing. I understand that a negative drug screen is required for employment. I understand that any offer of employment is contingent upon Associate Medical Professionals obtaining satisfactory responses to reference inquiries as well as completing and/or submitting all required paperwork. I understand that the decision to hire may also be based upon my ability and desire to fill the current assignment needs of Associate Medical Professionals.
* Date	02/05/2012
* Name
* Social Security Number	- -

staffing@associatemedical.com

Ph: 405-943-7900
888-456-0860
Fax: 405-943-7947
888-575-7374

5116 N. Portland Ave, Ste. 100
Oklahoma City, OK 73112
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Classification	RN LPN CNA AUA OR Scrub Tech OB Scrub Tech Unit Coordinator/Secretary
Special Conditions	I am a former employee of AMP I am currently a clinical nursing student
* Areas of Experience	Acute Care Hospital Rehabilitation Hospital Nursing Home / Assisted Living Skilled Nursing Facility Home Care Psychiatric Hospital Clinic Long Term Acute Care OccMed Corrections Other:

* Regular Clinical or Hospital Experience (6+ months of experience)	ACLS Certified NALS Certified PALS Certified Bone Marrow Transplant Cardiac Cath Lab Cardiac ICU ER/Trauma Hemodialysis Gero Psych Labor & Delivery Medical/Surgical ICU Med/Surg Neonatal ICU Newborn Nursery OccMed OR Circulate OR Scrub Oncology Ortho/Neuro Peds GYN/PP Psychiatry Rehab Recovery Room SkilledNursing PCCU/Telemetry
NeoNatal ICU experience level	1 2 3
Other Experience

How much do you plan to work?	Full Time Part Time If part time, how many hours per week?
When are you available and expect to work? (Select all that apply)	7 - 3 3 - 11 11 - 7 7AM - 7PM 7PM - 7AM Weekdays Weekends Holidays Doubles Every Week Every Other Week Weekends Only Just Now and Then Other: