Date:
Name:
Email Address:
Home Phone:
Other Phone :
Township/Borough:
School District:
Street:
State:
City:
Zip Code :
Position (choose one): RN LPN CNA CMA Private Duty Staffing Both
Nurses License No. Certified Nurses Aide No.
Have you ever worked under another name? Yes No
If yes, what other names or names?
Are you at least 18 years of age? Yes No
Have you ever worked for this company before? Yes No
Where? When?
Have you ever been convicted of any prohibitive offenses as contained in act 169 of 1996 as amended by act 13 of 1997? . LINK GOES HERE! Yes No
If yes, give details:
Do you have a resident Alien Card? Yes No
Card # Expiration Date: (Verification will be required upon hire)
Do you have current CPR? Yes No Expiration Date:
Date of last physical (month & year).
Date of last TB test. neg. pos.
Were you inoculated with the hepatitis b vaccination series? Yes No
Do you own your own car? Yes No
Are you presently working? Click Here... yes no full-time part-time
I UNDERSTAND NURSES AVAILABLE STAFFING OPERATES 24 HOURS A DAY, 7 DAYS A WEEK AND I WILL BE CALLED FOR ALL AVAILABLE SHIFTS. DO YOU AGREE: Click Here... Yes No
Date Month & Year
Name and Address of Employer
Reason for Leaving
From:
To:
REFERENCES: (List 3 work related references in the medical field. People you worked for or reported to.
Name
Complete Address
Phone#
STATEMENT OF CERTIFICATION
I hereby certify, under penalty of immediate dismissal, that this application for employment has been completed fully and correctly.
I understand that inquires may be made to former employers or their agents, to personal references, and to others with whom I am have been acquainted; and that those inquires may include information regarding my character, my general reputation, my personal characteristics, and my overall working attitude. My permission is hereby granted to make such inquires.
If I am accepted for employment with this agency, I agree to abide by its personnel policies and also to report to my supervisor any and all job related accidents and illness within twenty-four (24) hours of their occurence, regardless of severity.
Further, I undestand and agree that my employment is for no definite period and may regardless of the date of payment of my wages and salary, be terminated at any time without any previous notice.
I HAVE READ AND UNDERSTAND THE JOB DESCRIPTION FOR THE POSITION APPLIED. I AM ABLE TO PERFORM ALL DUTIES AS DESCRIBED. DO YOU AGREE: Click Here... Yes No
IF NO, PLEASE DESCRIBE WHICH DUTIES YOU ARE UNABLE TO PERFORM AND WHAT ACCOMODATIONS MAY BE NECESSARY.
Comments:
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"Nurses Available has been invaluable to me over the past year and a half." -- S.G.
