New Mexico
Medical Staffing Inc.

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Our Goal
Employment Eligibility Verification
FORM WILL ALSO NEED TO BE FILLED OUT FOR ALL APPLICANTS
For more information Click Here
To download the form Click Here for English
Or Click Here for Spanish (Haga clic Aqui Para espanol)

PERSONAL INFORMATION


   Name                                                                                    			         Date : (ex:10/10/08)

      First:  		Last:         	 

      SS#  		DOB  
 
 Address  

       Street:    	  City: 
 
      Zipcode:        Select State:
     (5 digits)

      Home Phone: 	          Cell Phone:  
      (Numbers only no dashes)
 
      Specialty 
 
      License # 	State:


EDUCATION
		

   						 		    YEARS	              YEARS	   DEGREE
SCHOOL			   NAME OF SCHOOL		  LOCATION    	 ATTENDED	           GRADUATED	 AWARDED


VOCATIONAL/TECHNICAL			  	  

HOSPITAL           				  	

COLLEGE/UNVERSITY  				   	

POST GRADUATE      				  	

ADDTIONAL EDUCATION			  	

   
PROFESSIONAL REFERENCES

  			List the names of two licnsed Nurses: exclude relatives or former employers 


           NAME		              ADDRESS  				   	   TELEPHONE# 
                  
                  
                 




WORK HISTORY



   Name of Employment:			                                PHONE:                                                         			        
    	 		         	 
      Address:                                          			        SALARY:
    	 		  
       Job Title: 
    	   
    		 
      Dates Worked
      
     	From                                                     To               	                                        HRS/WK
    	    	    	    	
      
      Supervisor						Shift
    	        	      
    	
      Duties
    	
    	

     Name of Employment:			                                PHONE:                                                         			        
    	 		         	 
      Address:                                          			        SALARY:
    	 		  
       Job Title: 
    	   
    		 
      Dates Worked
      
     	From                                                     To               	                                        HRS/WK
    	    	    	    	
      
      Supervisor						Shift
    	        	      
    	
      Duties
    	
    	
     Reason For Leaving
     	
     	
EMPLOYER REFERENCES

     	NAME                                           				PHONE#
    	 		 
     	NAME                                           				PHONE#
    	 		 
     	
      
      
     

										  


			New Mexico Staffing Services is an equal opportunity employer


	      All persons shall have the opportunity to be considered for employment without regard to their Race, color, 
	  religion, national origin or ancestry, age, disability, sex, martial status, liability, for services in the armed forces 
	                            of the United States, citizenship, or any other charcteristics protected by law.