{"id":22,"date":"2015-07-28T15:26:44","date_gmt":"2015-07-28T15:26:44","guid":{"rendered":"http:\/\/moorenurses.com\/TravelNurse\/?page_id=22"},"modified":"2015-09-10T15:36:17","modified_gmt":"2015-09-10T15:36:17","slug":"registertest","status":"publish","type":"page","link":"http:\/\/moorenurses.com\/travelnurse\/","title":{"rendered":"Moore Nurses Registration"},"content":{"rendered":"<h2 style=\"text-align: center;\"><strong>Moore Nurses Registration<\/strong><\/h2>\n<p style=\"text-align: center;\"><script type=\"text\/javascript\">if(!gform){document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0});var gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),null==t&&(t=10),gform.hooks[o][n].push({tag:i,callable:r,priority:t})},doHook:function(o,n,r){if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[o][n]){var t,i=gform.hooks[o][n];i.sort(function(o,n){return o.priority-n.priority});for(var e=0;e<i.length;e++)\"function\"!=typeof(t=i[e].callable)&&(t=window[t]),\"action\"==o?t.apply(null,r):r[0]=t.apply(null,r)}if(\"filter\"==o)return r[0]},removeHook:function(o,n,r,t){if(null!=gform.hooks[o][n])for(var i=gform.hooks[o][n],e=i.length-1;0<=e;e--)null!=t&&t!=i[e].tag||null!=r&&r!=i[e].priority||i.splice(e,1)}}}<\/script>\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper' id='gform_wrapper_2' style='display:none'><div id='gf_2' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data'  id='gform_2'  action='\/travelnurse\/wp-json\/wp\/v2\/pages\/22#gf_2' novalidate>\n                        <div class='gform_body gform-body'><div id='gform_page_2_1' class='gform_page' >\n                                    <div class='gform_page_fields'><ul id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_2_509\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h2 class=\"gsection_title\">1. Contact &amp; Registration<\/h2><\/li><li id=\"field_2_4\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_2_4'>\n                            \n                            <span id='input_2_4_3_container' class='name_first' >\n                                                    <input type='text' name='input_4.3' id='input_2_4_3' value='' aria-label='First name'   aria-required='true'     \/>\n                                                    <label for='input_2_4_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_2_4_6_container' class='name_last' >\n                                                    <input type='text' name='input_4.6' id='input_2_4_6' value='' aria-label='Last name'   aria-required='true'     \/>\n                                                    <label for='input_2_4_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_2_5\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_5' >Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_5' id='input_2_5' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_2_6\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_6' >Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_6' id='input_2_6' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_578\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_578' >Home Address, Apt #, State &amp; Zip<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_578' id='input_2_578' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_579\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_579' >Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_579' id='input_2_579' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_580\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_580' >Last 4 # of Social Security Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_580' id='input_2_580' type='text' value='' class='medium' maxlength='4'    aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_586\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_2_586' >Covid-19 Vaccination Card: If you have a Covid-19 card, please upload a copy now.<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='1610612736' \/><input name='input_586' id='input_2_586' type='file' class='large' aria-describedby=\"gfield_upload_rules_2_586\" onchange='javascript:gformValidateFileSize( this, 1610612736 );'  \/><span class='gform_fileupload_rules' id='gfield_upload_rules_2_586'>Accepted file types: pdf, doc, docx, jpg, jpeg, png, tiff, Max. file size: 2 GB.<\/span><div class='validation_message validation_message--hidden-on-empty' id='live_validation_message_2_586'><\/div><\/div><\/li><li id=\"field_2_32\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_32' >Specialty Applying For:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_32' id='input_2_32' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='ICU' >ICU<\/option><option value='Tele' >Tele<\/option><option value='Med-Surg\/Tele' >Med-Surg\/Tele<\/option><option value='L&amp;D' >L&amp;D<\/option><option value='NICU' >NICU<\/option><option value='PACU' >PACU<\/option><option value='PP' >PP<\/option><option value='OR' >OR<\/option><option value='ER' >ER<\/option><option value='Pedi' >Pedi<\/option><option value='PICU' >PICU<\/option><option value='Step-Down' >Step-Down<\/option><option value='CVICU' >CVICU<\/option><option value='CVOR' >CVOR<\/option><option value='CATH LAB' >CATH LAB<\/option><\/select><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_2_511' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"2\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"2\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_2' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_2_2' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_2_510\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h2 class=\"gsection_title\">2. RN License(s)<\/h2><\/li><li id=\"field_2_577\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_577' >List all active State RN License(s) &amp; Expiration Date(s). Example: Texas 123456 01\/01\/2024<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_577' id='input_2_577' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_2_583\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_583' >Please list your (AHA) Heart Cards &amp; certifications with expiration dates.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_583' id='input_2_583' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_2_512\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h2 class=\"gsection_title\">RN License Information<\/h2><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_2_11' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"1\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"1\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_2_11' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"3\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"3\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_3' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_2_3' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_2_36\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h2 class=\"gsection_title\">3. Resume \/ Work History &amp; Education<\/h2><\/li><li id=\"field_2_37\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_37' >Please select how you would       like to submit your last seven (7) years work history and education. *IMPORTANT* you must       provide the Start &amp; End Month and Year for each position provided. If       you submit your resume please ensure the dates are included.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_37' id='input_2_37' class='medium gfield_select'  aria-describedby=\"gfield_description_2_37\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='I have a current copy. I will attach it.' >I have a current copy. I will attach it.<\/option><option value='I need to fill one out.' >I need to fill one out.<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_2_37'>*IMPORTANT* you must provide the Start &amp; End Month and Year for each position provided. If you submit your resume please ensure the dates are included. <\/div><\/li><li id=\"field_2_10\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_10' >Please attach your Resume or Work History &amp; Education Form below.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='1610612736' \/><input name='input_10' id='input_2_10' type='file' class='medium' aria-describedby=\"gfield_upload_rules_2_10\" onchange='javascript:gformValidateFileSize( this, 1610612736 );'  \/><span class='gform_fileupload_rules' id='gfield_upload_rules_2_10'>Accepted file types: pdf, doc, docx, jpg, jpeg, png, tiff, Max. file size: 2 GB.<\/span><div class='validation_message validation_message--hidden-on-empty' id='live_validation_message_2_10'><\/div><\/div><\/li><li id=\"field_2_54\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h2 class=\"gsection_title\">Please Click Next To Begin Online Work History And Education Form<\/h2><\/li><li id=\"field_2_39\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h2 class=\"gsection_title\">Education<\/h2><\/li><li id=\"field_2_40\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_40' >Name of School<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_40' id='input_2_40' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_82\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_city has_state ginput_container_address' id='input_2_82' >\n                        <span class='ginput_left address_city ginput_address_city' id='input_2_82_3_container' >\n                                    <input type='text' name='input_82.3' id='input_2_82_3' value=''    aria-required='true'    \/>\n                                    <label for='input_2_82_3' id='input_2_82_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_2_82_4_container' >\n                                        <input type='text' name='input_82.4' id='input_2_82_4' value=''      aria-required='true'    \/>\n                                        <label for='input_2_82_4' id='input_2_82_4_label' >State \/ Province \/ Region<\/label>\n                                      <\/span><input type='hidden' class='gform_hidden' name='input_82.6' id='input_2_82_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_2_43\" class=\"gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_43' >Degree Achieved<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_2_43' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_44\" class=\"gfield gf_right_half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_44' >Graduated<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_44' id='input_2_44' type='text' value='' class='datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_44_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_44_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_44' class='gform_hidden' value='http:\/\/moorenurses.com\/travelnurse\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_2_52\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h2 class=\"gsection_title\">Education Continued<\/h2><\/li><li id=\"field_2_46\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_46' >Name of School<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_2_46' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_81\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Address<\/label>    \n                    <div class='ginput_complex ginput_container has_city has_state ginput_container_address' id='input_2_81' >\n                        <span class='ginput_left address_city ginput_address_city' id='input_2_81_3_container' >\n                                    <input type='text' name='input_81.3' id='input_2_81_3' value=''    aria-required='false'    \/>\n                                    <label for='input_2_81_3' id='input_2_81_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_2_81_4_container' >\n                                        <input type='text' name='input_81.4' id='input_2_81_4' value=''      aria-required='false'    \/>\n                                        <label for='input_2_81_4' id='input_2_81_4_label' >State \/ Province \/ Region<\/label>\n                                      <\/span><input type='hidden' class='gform_hidden' name='input_81.6' id='input_2_81_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_2_50\" class=\"gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_50' >Degree Achieved<\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_2_50' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_51\" class=\"gfield gf_right_half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_51' >Graduated<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_51' id='input_2_51' type='text' value='' class='datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_51_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_51_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_51' class='gform_hidden' value='http:\/\/moorenurses.com\/travelnurse\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_2_12\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h2 class=\"gsection_title\">Work History<\/h2><div class='gsection_description' id='gfield_description_2_12'>Please list your last 7 years work history. You must include the start and end date of employment. You only need to be accurate to the Month &amp; Year. If you are currently employed put today's date as the Date End Employed.<\/div><\/li><li id=\"field_2_529\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h2 class=\"gsection_title\">Employment 1<\/h2><\/li><li id=\"field_2_527\" class=\"gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_527' >Date Started Employment<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_527' id='input_2_527' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_527_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_2_527_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_527' class='gform_hidden' value='http:\/\/moorenurses.com\/travelnurse\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_2_528\" class=\"gfield gf_right_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_528' >Date End Employment<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_528' id='input_2_528' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_528_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_2_528_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_528' class='gform_hidden' value='http:\/\/moorenurses.com\/travelnurse\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_2_539\" class=\"gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_539' >Employer Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_539' id='input_2_539' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_540\" class=\"gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_540' >Position &amp; Specialty<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_540' id='input_2_540' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_543\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Location<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_city has_state ginput_container_address' id='input_2_543' >\n                        <span class='ginput_left address_city ginput_address_city' id='input_2_543_3_container' >\n                                    <input type='text' name='input_543.3' id='input_2_543_3' value=''    aria-required='true'    \/>\n                                    <label for='input_2_543_3' id='input_2_543_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_2_543_4_container' >\n                                        <input type='text' name='input_543.4' id='input_2_543_4' value=''      aria-required='true'    \/>\n                                        <label for='input_2_543_4' id='input_2_543_4_label' >State \/ Province \/ Region<\/label>\n                                      <\/span><input type='hidden' class='gform_hidden' name='input_543.6' id='input_2_543_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_2_544\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_544' >Duties<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_544' id='input_2_544' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_2_530\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h2 class=\"gsection_title\">Employment 2<\/h2><\/li><li id=\"field_2_531\" class=\"gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_531' >Date Started Employment<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_531' id='input_2_531' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_531_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_531_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_531' class='gform_hidden' value='http:\/\/moorenurses.com\/travelnurse\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_2_532\" class=\"gfield gf_right_half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_532' >Date End Employment<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_532' id='input_2_532' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_532_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_532_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_532' class='gform_hidden' value='http:\/\/moorenurses.com\/travelnurse\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_2_542\" class=\"gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_542' >Employer Name<\/label><div class='ginput_container ginput_container_text'><input name='input_542' id='input_2_542' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_546\" class=\"gfield gf_right_half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_546' >Position &amp; Speciality<\/label><div class='ginput_container ginput_container_text'><input name='input_546' id='input_2_546' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_547\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Location<\/label>    \n                    <div class='ginput_complex ginput_container has_city has_state ginput_container_address' id='input_2_547' >\n                        <span class='ginput_left address_city ginput_address_city' id='input_2_547_3_container' >\n                                    <input type='text' name='input_547.3' id='input_2_547_3' value=''    aria-required='false'    \/>\n                                    <label for='input_2_547_3' id='input_2_547_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_2_547_4_container' >\n                                        <input type='text' name='input_547.4' id='input_2_547_4' value=''      aria-required='false'    \/>\n                                        <label for='input_2_547_4' id='input_2_547_4_label' >State \/ Province \/ Region<\/label>\n                                      <\/span><input type='hidden' class='gform_hidden' name='input_547.6' id='input_2_547_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_2_548\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_548' >Duties<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_548' id='input_2_548' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_2_533\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h2 class=\"gsection_title\">Employment 3<\/h2><\/li><li id=\"field_2_536\" class=\"gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_536' >Date Started Employment<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_536' id='input_2_536' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_536_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_536_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_536' class='gform_hidden' value='http:\/\/moorenurses.com\/travelnurse\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_2_537\" class=\"gfield gf_right_half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_537' >Date End Employment<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_537' id='input_2_537' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_537_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_537_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_537' class='gform_hidden' value='http:\/\/moorenurses.com\/travelnurse\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_2_541\" class=\"gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_541' >Employer Name<\/label><div class='ginput_container ginput_container_text'><input name='input_541' id='input_2_541' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_545\" class=\"gfield gf_right_half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_545' >Position &amp; Speciality<\/label><div class='ginput_container ginput_container_text'><input name='input_545' id='input_2_545' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_549\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Location<\/label>    \n                    <div class='ginput_complex ginput_container has_city has_state ginput_container_address' id='input_2_549' >\n                        <span class='ginput_left address_city ginput_address_city' id='input_2_549_3_container' >\n                                    <input type='text' name='input_549.3' id='input_2_549_3' value=''    aria-required='false'    \/>\n                                    <label for='input_2_549_3' id='input_2_549_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_2_549_4_container' >\n                                        <input type='text' name='input_549.4' id='input_2_549_4' value=''      aria-required='false'    \/>\n                                        <label for='input_2_549_4' id='input_2_549_4_label' >State \/ Province \/ Region<\/label>\n                                      <\/span><input type='hidden' class='gform_hidden' name='input_549.6' id='input_2_549_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_2_550\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_550' >Duties<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_550' id='input_2_550' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_2_534\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h2 class=\"gsection_title\">Employment 4<\/h2><\/li><li id=\"field_2_535\" class=\"gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_535' >Date Started Employment<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_535' id='input_2_535' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_535_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_535_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_535' class='gform_hidden' value='http:\/\/moorenurses.com\/travelnurse\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_2_538\" class=\"gfield gf_right_half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_538' >Date End Employment<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_538' id='input_2_538' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_538_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_538_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_538' class='gform_hidden' value='http:\/\/moorenurses.com\/travelnurse\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_2_551\" class=\"gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_551' >Employer Name<\/label><div class='ginput_container ginput_container_text'><input name='input_551' id='input_2_551' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_552\" class=\"gfield gf_right_half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_552' >Position &amp; Specialty<\/label><div class='ginput_container ginput_container_text'><input name='input_552' id='input_2_552' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_553\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Location<\/label>    \n                    <div class='ginput_complex ginput_container has_city has_state ginput_container_address' id='input_2_553' >\n                        <span class='ginput_left address_city ginput_address_city' id='input_2_553_3_container' >\n                                    <input type='text' name='input_553.3' id='input_2_553_3' value=''    aria-required='false'    \/>\n                                    <label for='input_2_553_3' id='input_2_553_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_2_553_4_container' >\n                                        <input type='text' name='input_553.4' id='input_2_553_4' value=''      aria-required='false'    \/>\n                                        <label for='input_2_553_4' id='input_2_553_4_label' >State \/ Province \/ Region<\/label>\n                                      <\/span><input type='hidden' class='gform_hidden' name='input_553.6' id='input_2_553_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_2_554\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_554' >Duties<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_554' id='input_2_554' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_2_555\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h2 class=\"gsection_title\">Employment 5<\/h2><\/li><li id=\"field_2_556\" class=\"gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_556' >Date Started Employment<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_556' id='input_2_556' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_556_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_556_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_556' class='gform_hidden' value='http:\/\/moorenurses.com\/travelnurse\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_2_557\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_557' >Date Ended Employment<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_557' id='input_2_557' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_557_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_557_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_557' class='gform_hidden' value='http:\/\/moorenurses.com\/travelnurse\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_2_558\" class=\"gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_558' >Employer Name<\/label><div class='ginput_container ginput_container_text'><input name='input_558' id='input_2_558' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_559\" class=\"gfield gf_right_half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_559' >Position &amp; Specialty<\/label><div class='ginput_container ginput_container_text'><input name='input_559' id='input_2_559' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_560\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Location<\/label>    \n                    <div class='ginput_complex ginput_container has_city has_state ginput_container_address' id='input_2_560' >\n                        <span class='ginput_left address_city ginput_address_city' id='input_2_560_3_container' >\n                                    <input type='text' name='input_560.3' id='input_2_560_3' value=''    aria-required='false'    \/>\n                                    <label for='input_2_560_3' id='input_2_560_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_2_560_4_container' >\n                                        <input type='text' name='input_560.4' id='input_2_560_4' value=''      aria-required='false'    \/>\n                                        <label for='input_2_560_4' id='input_2_560_4_label' >State \/ Province \/ Region<\/label>\n                                      <\/span><input type='hidden' class='gform_hidden' name='input_560.6' id='input_2_560_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_2_561\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_561' >Duties<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_561' id='input_2_561' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_2_562\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Would you like to add more history?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_562'>\n\t\t\t<li class='gchoice gchoice_2_562_0'>\n\t\t\t\t<input name='input_562' type='radio' value='Yes'  id='choice_2_562_0'    \/>\n\t\t\t\t<label for='choice_2_562_0' id='label_2_562_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_562_1'>\n\t\t\t\t<input name='input_562' type='radio' value='No'  id='choice_2_562_1'    \/>\n\t\t\t\t<label for='choice_2_562_1' id='label_2_562_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_563\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h2 class=\"gsection_title\">Employment 6<\/h2><\/li><li id=\"field_2_564\" class=\"gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_564' >Date Started Employment<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_564' id='input_2_564' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_564_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_564_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_564' class='gform_hidden' value='http:\/\/moorenurses.com\/travelnurse\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_2_565\" class=\"gfield gf_right_half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_565' >Date Ended Employment<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_565' id='input_2_565' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_565_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_565_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_565' class='gform_hidden' value='http:\/\/moorenurses.com\/travelnurse\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_2_566\" class=\"gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_566' >Employer Name<\/label><div class='ginput_container ginput_container_text'><input name='input_566' id='input_2_566' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_567\" class=\"gfield gf_right_half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_567' >Position &amp; Specialty<\/label><div class='ginput_container ginput_container_text'><input name='input_567' id='input_2_567' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_568\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Location<\/label>    \n                    <div class='ginput_complex ginput_container has_city has_state ginput_container_address' id='input_2_568' >\n                        <span class='ginput_left address_city ginput_address_city' id='input_2_568_3_container' >\n                                    <input type='text' name='input_568.3' id='input_2_568_3' value=''    aria-required='false'    \/>\n                                    <label for='input_2_568_3' id='input_2_568_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_2_568_4_container' >\n                                        <input type='text' name='input_568.4' id='input_2_568_4' value=''      aria-required='false'    \/>\n                                        <label for='input_2_568_4' id='input_2_568_4_label' >State \/ Province \/ Region<\/label>\n                                      <\/span><input type='hidden' class='gform_hidden' name='input_568.6' id='input_2_568_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_2_569\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_569' >Untitled<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_569' id='input_2_569' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_2_572' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"2\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"2\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_2_572' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"4\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"4\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_4' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_2_4' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_2_21\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h2 class=\"gsection_title\">4.  Professional Reference Form<\/h2><div class='gsection_description' id='gfield_description_2_21'>Please provide a minimum of two (2) professional references in your specialty. References must cover twelve (12) months of work from your last thirty six (36) months of experience (hospital requirement). Include the Hospital Name you worked at with the reference. <\/div><\/li><li id=\"field_2_56\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_56' >You can provide your references by uploading a document or by filling in a web form. I would like to:<\/label><div class='ginput_container ginput_container_select'><select name='input_56' id='input_2_56' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='Provide my references via web form.' >Provide my references via web form.<\/option><option value='Upload a list of references' >Upload a list of references<\/option><\/select><\/div><\/li><li id=\"field_2_57\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_57' >File<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='1610612736' \/><input name='input_57' id='input_2_57' type='file' class='medium' aria-describedby=\"gfield_upload_rules_2_57\" onchange='javascript:gformValidateFileSize( this, 1610612736 );'  \/><span class='gform_fileupload_rules' id='gfield_upload_rules_2_57'>Accepted file types: pdf, doc, docx, jpg, Max. file size: 2 GB.<\/span><div class='validation_message validation_message--hidden-on-empty' id='live_validation_message_2_57'><\/div><\/div><\/li><li id=\"field_2_70\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h2 class=\"gsection_title\">Reference 1<\/h2><\/li><li id=\"field_2_22\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Reference Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_2_22'>\n                            \n                            <span id='input_2_22_3_container' class='name_first' >\n                                                    <input type='text' name='input_22.3' id='input_2_22_3' value='' aria-label='First name'   aria-required='true'     \/>\n                                                    <label for='input_2_22_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_2_22_6_container' class='name_last' >\n                                                    <input type='text' name='input_22.6' id='input_2_22_6' value='' aria-label='Last name'   aria-required='true'     \/>\n                                                    <label for='input_2_22_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_2_23\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_23' >Reference &#039;s Unit\/Title<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_2_23' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_24\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_24' >Reference&#039;s Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_24' id='input_2_24' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_66\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_66' >Facility Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_66' id='input_2_66' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_26\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Location<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_city has_state ginput_container_address' id='input_2_26' >\n                        <span class='ginput_left address_city ginput_address_city' id='input_2_26_3_container' >\n                                    <input type='text' name='input_26.3' id='input_2_26_3' value=''    aria-required='true'    \/>\n                                    <label for='input_2_26_3' id='input_2_26_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_2_26_4_container' >\n                                        <input type='text' name='input_26.4' id='input_2_26_4' value=''      aria-required='true'    \/>\n                                        <label for='input_2_26_4' id='input_2_26_4_label' >State \/ Province \/ Region<\/label>\n                                      <\/span><input type='hidden' class='gform_hidden' name='input_26.6' id='input_2_26_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_2_67\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_67' >Position During Employment<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_67' id='input_2_67' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_68\" class=\"gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_68' >Date Start Employed<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_68' id='input_2_68' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_68_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_2_68_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_68' class='gform_hidden' value='http:\/\/moorenurses.com\/travelnurse\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_2_69\" class=\"gfield gf_right_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_69' >Date End Employed<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_69' id='input_2_69' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_69_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_2_69_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_69' class='gform_hidden' value='http:\/\/moorenurses.com\/travelnurse\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_2_71\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h2 class=\"gsection_title\">Reference 2<\/h2><\/li><li id=\"field_2_73\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Reference Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_2_73'>\n                            \n                            <span id='input_2_73_3_container' class='name_first' >\n                                                    <input type='text' name='input_73.3' id='input_2_73_3' value='' aria-label='First name'   aria-required='true'     \/>\n                                                    <label for='input_2_73_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_2_73_6_container' class='name_last' >\n                                                    <input type='text' name='input_73.6' id='input_2_73_6' value='' aria-label='Last name'   aria-required='true'     \/>\n                                                    <label for='input_2_73_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_2_74\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_74' >Reference &#039;s Unit\/Title<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_74' id='input_2_74' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_75\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_75' >Reference&#039;s Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_75' id='input_2_75' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_76\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_76' >Facility Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_76' id='input_2_76' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_77\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Location<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_city has_state ginput_container_address' id='input_2_77' >\n                        <span class='ginput_left address_city ginput_address_city' id='input_2_77_3_container' >\n                                    <input type='text' name='input_77.3' id='input_2_77_3' value=''    aria-required='true'    \/>\n                                    <label for='input_2_77_3' id='input_2_77_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_2_77_4_container' >\n                                        <input type='text' name='input_77.4' id='input_2_77_4' value=''      aria-required='true'    \/>\n                                        <label for='input_2_77_4' id='input_2_77_4_label' >State \/ Province \/ Region<\/label>\n                                      <\/span><input type='hidden' class='gform_hidden' name='input_77.6' id='input_2_77_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_2_78\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_78' >Position During Employment<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_78' id='input_2_78' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_79\" class=\"gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_79' >Date Start Employed<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_79' id='input_2_79' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_79_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_2_79_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_79' class='gform_hidden' value='http:\/\/moorenurses.com\/travelnurse\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_2_80\" class=\"gfield gf_right_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_80' >Date End Employed<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_80' id='input_2_80' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_80_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_2_80_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_80' class='gform_hidden' value='http:\/\/moorenurses.com\/travelnurse\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_2_513' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"3\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"3\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_2_513' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"5\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"5\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_5' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_2_5' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_2_576\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h2 class=\"gsection_title\">5. Pre-Qualification Application<\/h2><\/li><li id=\"field_2_19\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h2 class=\"gsection_title\">3 Question Attestation<\/h2><\/li><li id=\"field_2_17\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Can you submit verification of your legal right to work in the U.S.?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_17'>\n\t\t\t<li class='gchoice gchoice_2_17_0'>\n\t\t\t\t<input name='input_17' type='radio' value='Yes'  id='choice_2_17_0'    \/>\n\t\t\t\t<label for='choice_2_17_0' id='label_2_17_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_17_1'>\n\t\t\t\t<input name='input_17' type='radio' value='No'  id='choice_2_17_1'    \/>\n\t\t\t\t<label for='choice_2_17_1' id='label_2_17_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_16\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Have you ever been named as a defendant in a professional liability claim?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_16'>\n\t\t\t<li class='gchoice gchoice_2_16_0'>\n\t\t\t\t<input name='input_16' type='radio' value='Yes'  id='choice_2_16_0'    \/>\n\t\t\t\t<label for='choice_2_16_0' id='label_2_16_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_16_1'>\n\t\t\t\t<input name='input_16' type='radio' value='No'  id='choice_2_16_1'    \/>\n\t\t\t\t<label for='choice_2_16_1' id='label_2_16_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_574\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_574' >Comment:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_574' id='input_2_574' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_2_15\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Has your professional license ever been investigated or suspended?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_15'>\n\t\t\t<li class='gchoice gchoice_2_15_0'>\n\t\t\t\t<input name='input_15' type='radio' value='Yes'  id='choice_2_15_0'    \/>\n\t\t\t\t<label for='choice_2_15_0' id='label_2_15_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_15_1'>\n\t\t\t\t<input name='input_15' type='radio' value='No'  id='choice_2_15_1'    \/>\n\t\t\t\t<label for='choice_2_15_1' id='label_2_15_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_575\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_575' >Comment:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_575' id='input_2_575' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_2_515\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h2 class=\"gsection_title\">Pre-Interview Questionnaire<\/h2><\/li><li id=\"field_2_58\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_58' >Candidate Start\/Availability Date:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_58' id='input_2_58' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_58_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_2_58_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_58' class='gform_hidden' value='http:\/\/moorenurses.com\/travelnurse\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_2_62\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Do you expect to need any time off during this assignment (Hospital max is 5 days)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_62'>\n\t\t\t<li class='gchoice gchoice_2_62_0'>\n\t\t\t\t<input name='input_62' type='radio' value='Yes'  id='choice_2_62_0'    \/>\n\t\t\t\t<label for='choice_2_62_0' id='label_2_62_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_62_1'>\n\t\t\t\t<input name='input_62' type='radio' value='No'  id='choice_2_62_1'    \/>\n\t\t\t\t<label for='choice_2_62_1' id='label_2_62_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_60\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_60' >Please specify the dates you&#039;ll need off<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_60' id='input_2_60' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_2_63\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Does Candidate have 3 months experience with computerized charting in the past year?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_63'>\n\t\t\t<li class='gchoice gchoice_2_63_0'>\n\t\t\t\t<input name='input_63' type='radio' value='Yes'  id='choice_2_63_0'    \/>\n\t\t\t\t<label for='choice_2_63_0' id='label_2_63_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_63_1'>\n\t\t\t\t<input name='input_63' type='radio' value='No'  id='choice_2_63_1'    \/>\n\t\t\t\t<label for='choice_2_63_1' id='label_2_63_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_61\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Does Candidate have at least 1 year current experience in specialty in the past 3 years    (**if you&#039;re applying for PACU\/OR 2yrs current experience)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_61'>\n\t\t\t<li class='gchoice gchoice_2_61_0'>\n\t\t\t\t<input name='input_61' type='radio' value='Yes'  id='choice_2_61_0'    \/>\n\t\t\t\t<label for='choice_2_61_0' id='label_2_61_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_61_1'>\n\t\t\t\t<input name='input_61' type='radio' value='No'  id='choice_2_61_1'    \/>\n\t\t\t\t<label for='choice_2_61_1' id='label_2_61_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_64\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Is Candidate ok with floating?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_64'>\n\t\t\t<li class='gchoice gchoice_2_64_0'>\n\t\t\t\t<input name='input_64' type='radio' value='Yes'  id='choice_2_64_0'    \/>\n\t\t\t\t<label for='choice_2_64_0' id='label_2_64_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_64_1'>\n\t\t\t\t<input name='input_64' type='radio' value='No'  id='choice_2_64_1'    \/>\n\t\t\t\t<label for='choice_2_64_1' id='label_2_64_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_65\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Can Candidate insert own IV&#039;s?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_65'>\n\t\t\t<li class='gchoice gchoice_2_65_0'>\n\t\t\t\t<input name='input_65' type='radio' value='Yes'  id='choice_2_65_0'    \/>\n\t\t\t\t<label for='choice_2_65_0' id='label_2_65_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_65_1'>\n\t\t\t\t<input name='input_65' type='radio' value='No'  id='choice_2_65_1'    \/>\n\t\t\t\t<label for='choice_2_65_1' id='label_2_65_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_571\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h2 class=\"gsection_title\">General Questions<\/h2><\/li><li id=\"field_2_85\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Shift Preference<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_85'>\n\t\t\t<li class='gchoice gchoice_2_85_0'>\n\t\t\t\t<input name='input_85' type='radio' value='AM'  id='choice_2_85_0'    \/>\n\t\t\t\t<label for='choice_2_85_0' id='label_2_85_0'>AM<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_85_1'>\n\t\t\t\t<input name='input_85' type='radio' value='PM'  id='choice_2_85_1'    \/>\n\t\t\t\t<label for='choice_2_85_1' id='label_2_85_1'>PM<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_85_2'>\n\t\t\t\t<input name='input_85' type='radio' value='Either AM or PM'  id='choice_2_85_2'    \/>\n\t\t\t\t<label for='choice_2_85_2' id='label_2_85_2'>Either AM or PM<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_582\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_582' >Do you have a preferred destination city or state?<\/label><div class='ginput_container ginput_container_text'><input name='input_582' id='input_2_582' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_581\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_581' >List your recruiter with Moore Nurses or the person who referred you.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_581' id='input_2_581' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_34\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label'  >If you are applying for a California position, have you applied for a position at a Kaiser Permanente hospital in the last six (6) months?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_34'>\n\t\t\t<li class='gchoice gchoice_2_34_0'>\n\t\t\t\t<input name='input_34' type='radio' value='Yes'  id='choice_2_34_0'    \/>\n\t\t\t\t<label for='choice_2_34_0' id='label_2_34_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_34_1'>\n\t\t\t\t<input name='input_34' type='radio' value='No'  id='choice_2_34_1'    \/>\n\t\t\t\t<label for='choice_2_34_1' id='label_2_34_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_35\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_2_35' >Please list the date you applied, the name of the KP Hospital and if you did the Voice Advantage (VA) interview for the position.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_35' id='input_2_35' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_2_507\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Does Candidate have recent skills checklist on file?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_507'>\n\t\t\t<li class='gchoice gchoice_2_507_0'>\n\t\t\t\t<input name='input_507' type='radio' value='Yes' checked='checked' id='choice_2_507_0'    \/>\n\t\t\t\t<label for='choice_2_507_0' id='label_2_507_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_507_1'>\n\t\t\t\t<input name='input_507' type='radio' value='No'  id='choice_2_507_1'    \/>\n\t\t\t\t<label for='choice_2_507_1' id='label_2_507_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_584\" class=\"gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible\" ><div class='ginput_container ginput_container_text'><input name='input_584' 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