Placement Profile

Dear Traveler,

Thank you for applying with Professional Nursing Service. In order for us to provide you a suitable assignment, please answer the following questions:

Red text and boxes with yellow shading are REQUIRED fields.

Personal Information:
First Name:        Middle Initial:
Last Name:       

Profile Information:
Date you wish to travel:       
Have you ever been on a travel assignment before? Yes   No
If YES, what was most satisfying about your assignment?
What was most dissatisfying about your assignment?

Which geographical areas do you prefer?
My first choice is:       
My second choice is:       
My third choice is:       
Would you be flexible in taking travel assignments? Yes   No
If NO, please explain:
States you are currently licensed in:       
States you have been licensed in:       
States in which you have applied for licensure:       
In which specialty area(s) do you expect to work?

Please list as least three professional references other than your past employers:
Reference #1: Name:       Title:
  Phone:       Address:
Reference #2: Name:       Title:
  Phone:       Address:
Reference #3: Name:       Title:
  Phone:       Address:
What characteristics do you look for in an agency?
How did you hear about Professional Nursing Service? (please be specific):
Please provide us with any other information you feel is pertinent in reviewing your application:

I acknowledge that checking the box marked "yes" below, is equivalent to my personal written signature as it confirms my consent to and assurance of the truthfulness and validity of the information I have submitted on this form:
  Yes      Date: