Application Form2017-03-18T20:54:59+00:00

APPLICATION FORM

Personal Contact Information
I am applying for the position of:

RNLPNOther:

Are you legally authorized to work in the United States?
YesNo
In what states are you currently, or have ever been, licensed?

License number & Expiry Date

Has your license ever been investigated or revoked?
YesNo
If yes, please explain:
Have you ever been convicted of a felony?
YesNo
Driver's License Number & Issuing State:

Emergency Contact

Relationship:

Work Availability
Please check all shifts that you are available to work

Mon: DaysEveningsNights
Tue: DaysEveningsNights
Wed: DaysEveningsNights
Thu: DaysEveningsNights
Fri: DaysEveningsNights
Sat: DaysEveningsNights
Sun: DaysEveningsNights

Full TimePart Time8-Hour Shifts12-Hour ShiftsStaff ReliefVisits Only

Nurses are required to rotate weekends

Education
High School:

College/Trade School:

Employment History

List all employers for the past five years. List the most recent first.


Start Date:
End Date:

Hourly Rate: $
.
/hr


Start Date:
End Date:

Hourly Rate: $
.
/hr


Start Date:
End Date:

Hourly Rate: $
.
/hr

References

List three professional references who have known you for at least one year and have knowledge of your abilities and skills. No previous employers.

Resume

Please attach your most recent resume. PDF files only, does not exceed 12MB.
To save your Word Document as PDF, go to "Files" and select "Save As". Under "Format", select "PDF" and click "Save".

Agreement

PREFERRED REQUESTS THAT ALL FULL-TIME POSITIONS ASSIST WITH WEEKEND SHIFTS. FULL TIME MONDAY THROUGH FRIDAY POSITIONS ARE SOMETIMES AVAILABLE.
PREFERRED DOES NOT DISCRIMINATE ON THE BASIS OF RACE, COLOR, NATIONAL ORIGIN, RELIGION, HANDICAP OR AGE IN ADMISSIONS OR ACCESS TO EMPLOYMENT, NOR IN THE TREATMENT OF OUR EMPLOYEES IN OUR PROGRAMS AND ACTIVITIES.
I HAVE READ THE ABOVE APPLICATION. TO MY KNOWLEDGE, I HAVE ANSWERED ALL QUESTIONS TRUTHFULLY AND UNDERSTAND IF THESE AFFIRMATIONS ARE FOUND TO BE FALSE, IT WILL BE GROUNDS FOR IMMEDIATE DISMISSAL.

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