Nursing Employment Application

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(Company Name Here)

Nursing Employment Application

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DateLast NameFirst NameMiddle

Current Address

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Street AddressCityStateZip

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Contact Phone NumberSecond Phone Numbere-mail address

Desired Position

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Position Applying ForDate You Can StartSalary Desired

Nursing Licenses and Certifications

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License Number:EXP. DateCPR EXP.

Additional Information

Have you ever applied to or worked for this company before? ____Yes ____No If yes, When?______

If hired, do you have reliable means of transportation to and from work? ____Yes ____No

Are you at least 18 years old? (If under 18, hire is subject to verification that you are of minimum legal age.)

____Yes ____NO.

If hired, can you present evidence of your U.S. citizenship or proof of your legal right to live and work in this country? ____ Yes ____No

Have you ever had disciplinary action taken against any license, or are you currently the subject of a report or investigation? ____Yes ____No If yes, please explain:

Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation? ____Yes ____No

If no, describe the functions that cannot be performed.

Have you ever been convicted of a criminal offense (felony or misdemeanor) that would prohibit your employment in a healthcare facility? _____Yes _____No

If yes, state nature of crime(s), when and where convicted, and disposition of the case.

(No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The nature of the offense, date of the offense, the surrounding circumstances, and the relevance of the offense to the position(s) applied for may, however, be considered.)

(Company Name Here)

Nursing Employment Application

Education, Training and Experience

High School

______Yes____No______

NameYrs. CompletedDid you graduate?Degree or Diploma

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AddressCityStateZip Code

College/University:

______Yes____No______

NameYrs. CompletedDid you graduate?Degree or Diploma

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AddressCityStateZip Code

Vocational/Business:

______Yes____No______

NameYrs. CompletedDid you graduate?Degree or Diploma

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AddressCityStateZip Code

Health Care Training:

______Yes____No______

NameYrs. CompletedDid you graduate?Degree or Diploma

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AddressCityStateZip Code

References

List below three persons not related to you who have knowledge of your work performance within the last three years.

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First NameLast NameTelephone Number

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OccupationYears Acquaintede-mail address

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First NameLast NameTelephone Number

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OccupationYears Acquaintede-mail address

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First NameLast NameTelephone Number

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OccupationYears Acquaintede-mail address

(Company Name Here)

Nursing Employment Application

Employment History

List below all present and past employment starting with your most recent employer. Account for periods of unemployment. You must complete this section even if attaching a resume. (Last five years sufficient)

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Dates EmployedEmployers NameAddress

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Supervisors NamePositionSalary

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Reason For Leaving

May we contact this employer for a reference? ___Yes___No

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Dates EmployedEmployers NameAddress

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Supervisors NamePositionSalary

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Reason For Leaving

May we contact this employer for a reference? ___Yes___No

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Dates EmployedEmployers NameAddress

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Supervisors NamePositionSalary

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Reason For Leaving

May we contact this employer for a reference? ___Yes___No

(Company Name Here)

Nursing Employment Application

Authorization

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that if, employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and release the company from all liability for any damage that may result from utilization of such information. I also understand and agree that no representative of the company has any authority to enter into an agreement for employment for specified period of time, or to make any agreement contrary to the foregoing. Unless it is in writing and signed by an authorized company representative.

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DateSignature

Office Use

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Remarks

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Shift PreferenceDesired Location

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HiredPositionSalary