Application

Contact Information
First Name
Last Name
Email
Cell Phone
SSN
DOB
Address Information
Address 1
Address 2
City
State
Zip Code
Discipline
Discipline
Specialties
Specialty
Education History
School Name
Degree
Graduation Date
Degree Upload
References
Credentials
License State
License Exp Date
Compact
License Upload
CPR/BLS
CPR/BLS Expiration Date
CPR/BLS Upload
ACLS
ACLS Exp
ACLS Upload
PALS
PALS Exp
PALS Upload
Health Documents
TB Record - Annual
Upload TB Record
Hep B
Hep B Upload
MMR
MMR Upload
Varicella
Varicella Upload
Covid Record
Upload Covid Record
Has your professional license ever been investigated?
Disclosure & Authorization
In signing this application, I understand that Delta Medical Staffing, LLC makes no guarantee of employment or assignment, guarantees or offers of pay rates. I further authorize prudent background checks, drug screenings and credentialing, including review of qualifications, education and experience as required by Delta Medical Staffing, LLC and its clients. I understand that failure to complete on-boarding, orientation, committed shifts and/or maintain compliance with company or client policy and requirements can result in loss of assignments, contract specific pay packages and non-taxable monies. I understand that in the case of employment related disputes, matters will be mutually referred for arbitration. 
Signature