Applicant Information

    First Name

    Last Name

    Email

    Street Address

    City

    State

    Zip

    Referred to us by

    Telephone

    Cellphone

    Position(s) applied for
    CNALPNRNOther

    Date Available

    Date of Birth

    Hours Available

    Rate of Pay Expected per hour

    Please briefly outline the reason you are applying for employment at this company?


    How did you hear about us?



    YesNo

    - If currently employed, may we contact your employer?


    YesNo

    - Are you legally eligible for employment in this country?


    YesNo

    - Are you available to work overtime if required?


    YesNo

    - Have you applied with this company before?


    YesNo

    - Have you been employed at this company before?


    YesNo

    - Do you have any friends or family employed at this location?


    YesNo

    - If considered for hiring, will you agree to provide a criminal background check?


    YesNo

    - Have you been convicted of a crime?

    Please explain

    Educational Background

    List the previous three (3) educational institutions attended, beginning with the most recent.

    School #1

    City/State/Province

    Degree(s) / Diploma(s) Earned

    Graduated?
    YesNo


    School #2

    City/State/Province

    Degree(s) / Diploma(s) Earned

    Graduated?
    YesNo


    School #3

    City/State/Province

    Degree(s) / Diploma(s) Earned

    Graduated?
    YesNo

    Nursing Background

    What state Nursing License do you possess?

    Type

    Issue Date

    Expiration Date

    Valid States


    Type

    Issue Date

    Expiration Date

    Valid States



    Do you have the following?

    BLSYesNo

    Issue Date:

    Expiration Date:


    ACLSYesNo

    Issue Date:

    Expiration Date:

    Please answer the following questions.

    What do you think is the most difficult part of nursing?

    What was the best job you ever had and why?

    What was your least favorite job and what did you dislike about it?

    Think of the BEST supervisor you have ever had, what characteristics made that person a good manager?

    Think of the WORST supervisor you have ever had, what characteristics made that person a poor manager?

    How will you be able to contribute to providing high quality care?

    Imagine you have been on your feet and working hard all day. A customer that you have been dealing with is rude and impatient, what do you do?

    Type of charting systems used?

    Type of employment applicant is seeking (per diem, pt, ft)

    How far are you willing to travel from your home

    Employment Background

    Employer #1

    Telephone

    Address

    Job Title

    Employment Start Date

    Employment End Date

    Immediate Supervisor

    Supervisor Title

    Supervisor Phone #

    Reason for Leaving

    May we contact for reference?
    YesNo

    Summarize the type of work

    Employer #2

    Telephone

    Address

    Job Title

    Employment Start Date

    Employment End Date

    Immediate Supervisor

    Supervisor Title

    Supervisor Phone #

    Reason for Leaving

    May we contact for reference?
    YesNo

    Summarize the type of work

    Employer #3

    Telephone

    Address

    Job Title

    Employment Start Date

    Employment End Date

    Immediate Supervisor

    Supervisor Title

    Supervisor Phone #

    Reason for Leaving

    May we contact for reference?
    YesNo

    Summarize the type of work

    Employer #4

    Telephone

    Address

    Job Title

    Employment Start Date

    Employment End Date

    Immediate Supervisor

    Supervisor Title

    Supervisor Phone #

    Reason for Leaving

    May we contact for reference?
    YesNo

    Summarize the type of work


    References

    List the name, relationship, number of years acquainted, and phone number of three references. (No relatives please).

    Name

    Relationship

    Years Acquainted

    Phone Number

    Name

    Relationship

    Years Acquainted

    Phone Number

    Name

    Relationship

    Years Acquainted

    Phone Number

    I certify that all the information I have provided is true, complete and correct.

    • The information contained within this application or any cover letter or resume attached is not shared with any third parties. The information is used by the employer only as an aid in the hiring decision making process. The applicant, by signing the application gives the employer consent to collect the information contained herein and use for the purpose specified.

    • I authorize this company to investigate all statements contained on this application. I understand that any misrepresentation or omission of facts called for is cause for immediate disqualification and/or if employed, immediate dismissal.

    • I understand that if I am hired, I will be required to provide criminal background check at my cost, proof of identity and legal authority to work in Canada, proof of certifications or educational qualifications, and a drivers abstract (if applicable).

    • Furthermore, I understand and agree that if employed, I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same rights to terminate my employment at any time, with or without prior notice, except as may be required by law. This application does not in any way constitute an agreement or contract for employment.

    Applicant's Signature