NAME

TITLE

CURRENT POSITION

ADDRESS

CITY

STATE

ZIP

HOME PHONE #

WORK PHONE #

BEEPER PHONE #

EMPLOYER

SUPERVISOR'S NAME

TITLE

HOW LONG HAVE YOU HAD
YOUR CURRENT POSITION?

HOW LONG HAVE YOU BEEN
IN THE HEALTH CARE FIELD?

IF A NURSE, HOW LONG HAVE
YOU BEEN A NURSE?

ARE YOU CERTIFIED?

YES NO

DATE OF CERTIFICATION

AAHealth Care or ANCC

SHIFT PREFERENCE?

CALL PREFERENCE?

WHAT IS YOUR REASON FOR LEAVING?

WHEN CAN YOU TELEPHONE INTERVIEW (TI) (Please give date and time)
TONIGHT/TOMORROW? YES NO

IF NOT, WHEN  

WHEN CAN YOU FACE TO FACE INTERVIEW

CAN YOU START WITHIN 2 WEEKS AFTER GIVING NOTICE?
YES NO

IF NOT, WHEN  

WHAT WOULD KEEP YOU FROM
RESIGNING TOMORROW?

HAVE YOU INTERVIEWED AND/OR SENT RESUMES REGARDING NEW JOB OPPORTUNITIES IN THE LAST 6 MONTHS?
IF YES, PLEASE INDICATE THE FACILITIES WITH WHOM YOU ARE INTERVIEWING.

FACILITY:

FACILITY:

FACILITY:

FACILITY:

ARE YOU WORKING WITH OTHER RECRUITERS? YES NO ;
IF SO, WHO

WHERE ELSE HAVE YOU BEEN EMPLOYED?

• COMPANY

  FROM/TO

  DUTIES

• COMPANY

  FROM/TO

  DUTIES

WHAT IS YOUR CURRENT BASE SALARY: $

COMPENSATION REQUIREMENT: $

EDUCATION: SCHOOL

DEGREE/DIPLOMA

GRADUATION DATE

SCHOOL

DEGREE/DIPLOMA

GRADUATION DATE

REAL ESTATE DO YOU :

RENT OWN

COMMENTS

WHEN IS THE BEST TIME TO CALL YOU

AT HOME

AT WORK

PROVIDED WE FIND THE RIGHT OPPORTUNITY, YOU CAN:

INTERVIEW (DATE)

RESIGN (DATE)

START NEW JOB (DATE)

IS THERE ANYTHING, PERSONAL OR OTHERWISE, THAT WOULD KEEP YOU FROM STARTING A NEW POSITION: YES NO

COMMENTS