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Client
Services
Nurse and AHP Recruitment
If your healthcare facility has been affected by the shortage of qualified nurses, let us demonstrate how you could benefit from temporary nurse staffing. O'Grady Peyton offers a number of healthcare staffing services, including short-term travel nursing, long-term nursing, and temporary staffing of physical therapists. Learn more about our nurse staffing services...
Industry
Endorsements
Recommended by Leading Healthcare Organizations
Hear what those within the medical industry have to say about O'Grady Peyton. We have worked hard to establish our reputation as the leading recruiter of international nurses to work in the USA, UK, and Ireland. Our company focus on personalized service also extends to the relationships we nurture with our client facilities. Read healthcare industry endorsements for O'Grady Peyton...
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Online application
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Personal information
Please enter your full legal name as it appears on your Social Security Card.
* Last name: * First name: Middle name:
* Home phone: Mobile phone:
() - () - () -
* Email address:
Other names under which you have been employed:
Social security number (optional):
  (xxx-xx-xxxx)   
* Discipline:
* Current specialty: Other/Secondary specialty:
* Years of experience in your current specialty:
* How did you hear about us? 
Please provide specifics:
Rank your top three U.S. Regions:
First Choice: Second Choice: Third Choice:
Address information
Current address:
* Street address: * Country:
* City: * State/Province: * Zip/Postal code:
Permanent address:
Street address: Country:
City: State/Province: Zip code/Postal code:
Phone:
() -
Emergency Contact
Name of contact: Phone:
() -
Street address: Country:
City: State/Province: Zip code/Postal code:
License/Registration/Certification
License 1:
License type: License number:
Date of Issue:
(dd/MMM/yyyy)
State/Province: Expiration date:
(dd-MMM-yyyy)
Certification:
Have you passed the NCLEX?
* Have you passed the CGFNS?  
* Have you passed the IELTS?  
* Have you passed the TOEFL?  
* Have you passed the TSE?  
* Are you currently a Registered
   Midwife, ever held a License as
   a Registered Midwife or was
   Midwifery part of your basic
   nurse training?
 
Current malpractice insurance carrier name and address:
Current malpractice insurance carrier policy number:
While on assignment, O'Grady Peyton International offers you professional coverage of up to $2 million, paid for by the Company, with no additional cost to you.
Additional information
* Have you ever had your license or certification, in any state, investigated, suspended or had disciplinary action taken against it?
If yes, please give details and current status:
(Max 1000 char)
* Have you ever been convicted of a crime other than a minor traffic violation?
(Driving under the influence is not considered a minor traffic violation. Exceptions due to state employment law: Conviction(s) that have been sealed, expunged or eradicated and California Health & Safety Code §§11357 (b) & (c), 11360(c), 11364, 11365, 11550 marijuana-related convictions over 2 years old, should not be revealed.)
* Have you ever been named as a defendant in a professional liability action?
If yes, please give details and current status:
(Max 1000 char)
* Are you either a U.S. Citizen or can you submit verification of your legal right to work in the U.S.?
If no, please give details and current status:
(Max 1000 char)
Education
Education 1:
Professional education / College name:
* Graduation date: Degree:
  (dd-MMM-yyyy)
Major:
State/Province:
Employment history
Please indicate all of your employment for the past ten (10) years, beginning with your most recent employer. Please list each facility in which you have worked. If you were employed by a specific patient, this information should be documented. Supervisors are defined as persons having knowledge of your performance at each location.
May we contact your present employer?
Employer 1:
First facility name/employer:
* Facility/employer name: * Country:
* City: * State/Province:
Teaching hospital:
* Current employer?
* From:    (dd-MMM-yyyy) To:    (mm/dd/yyyy)
Reason for leaving:
* Position held: * Discipline:
* Unit/Floor/Dept: * Specialty:
* Supervisor's name: * Supervisor's title: * Supervisor's phone:
() -
Other Supervisor: Phone:
() -
Patient ratio: Number of
Beds in Unit:
Number of
Beds in Hospital:

I attest that I am the applicant and the information provided in this application is complete and accurate, to the best of my knowledge. Providing incomplete or inaccurate information may result in disqualification from the program, and may be a violation of state law(s) that could result in civil penalties. The Company is authorized to obtain information from my current and previous employers, and to release information in support of my application (application, references, background search results, etc.) to the Company's client institutions. The Company may also share information regarding my employment with its affiliates and appropriate governmental or licensing entities. I consent to receiving employment opportunity-related information at all phone numbers or email addresses that I provide. I understand that the Company, certain states and/or Client institutions may require criminal background checks, and I consent to such checks. Prior to conducting any background checks that qualify as consumer or investigative consumer reports, I will be provided, and will return, separate disclosure and acknowledgement forms as required by the Company.
* I agree with the above statements. * Date:    (dd-MMM-yyyy)



O'Grady Peyton International staffs nursing jobs for individuals wanting to work in the United States, UK, and Ireland. We staff travel nurses domestically, and fill long-term nursing and allied health assignments for international providers.
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