1. Please include the following information in your packet:

	Photograph: Original, recent Polaroid or passport photo. If you are coming in for an interview, we can take a photograph for you.
	Professional License(s): Copies of ALL current professional licenses and any license you have held in the past 5 to 10 years.
	Diploma/Degree: Copies of diploma and/or degree(s). If you do not have, or cannot get copies of, your diploma/degree(s), please complete the "Educational Statement" .
	CPR Certification: Must be American Heart Association Course C or American Red Cross Certification for the Healthcare Professional.
	ACLS Certification: Required for ER,ICU, Tele and PACU nurses. If you do not have current ACLS certification, it must be obtained prior to your start date. We will need a note stating the date, time and location of your course.
	PALS Certification: Required for ER, Peds, Nicu, PICU, Nursery.
	NRP Certification: Required for Maternal Child and Labor and Delivery departments. Preferred in ER.
	Proof of US Citizenship: Acceptable forms of ID include copy of unexpired US passport, birth certificate, or Alien Registration card, state driver’s license and SSN card.
	Any copies of professional certifications you may have i.e. CEN, CCRN, TNCC
	Physical: Evidence of physical within the sixty (60) days which includes PPD, Varicella, MMR for persons born 1957 or later, and hepatitis-B vaccination. If you have not had Hepatitis-B vaccination and do not wish to get it, please complete a Hepatitis-B Vaccination Waiver enclosed.

2.Applicants must complete all the following forms, which have been  provided for you on this web site. Please click on the titles below or follow the links on the Application Links page of this web site:

I-9  is for proof of US Citizenship. It is required for all applicants. Visit the Government INS website linked to this item and scroll down to the I-9 form.

Physical: Evidence of physical within the sixty (60) days which includes PPD, Varicella, MMR for persons born 1957 or later, and hepatitis-B vaccination. If you have not had Hepatitis-B vaccination and do not wish to get it, please complete a Hepatitis-B Vaccination Waiver enclosed.

Application Form: Complete this form on line or print and fax the completed form. Please mail the original, if you choose to fill it out manually.

Signature Forms: These forms must be completed by all applicants. Please print, sign and fax a copy, and mail the original.

Work References: Please complete first half of three (3) reference forms, including telephone numbers. If possible, have them completed by reference and sent to CCMS.

Voluntary Self Identification

W-4 - To be completed after hire.

Direct Deposit: To be completed after hire

Skills Check List: For Specialty (If applies)

Emergency Room	Medical Surgical	Intensive Care
Labor & Delivery	Mother Baby	Medical Assistant
Pharmacy Tech	OR Technician	Neonatal ICU
OR RN	Nursing Assistant

Addendum to Application for Patient Safety Specialist Positions

After completing the application, you may choose one of the following:

Email to Toni@CCMSstaffing.com, or

Fax to (610)667-2025, or

Mail to:     CCMS

                Toni Pettineo, RN, Staff Coordinator

                          33 Rock Hill Road, Suite 350

                Bala Cynwyd, PA 19004