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?




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?

BLS YesNo
Issue Date:
Expiration Date:


ACLS YesNo
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
Starting Hourly Rate
Ending Hourly Rate
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
Starting Hourly Rate
Ending Hourly Rate
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
Starting Hourly Rate
Ending Hourly Rate
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
Starting Hourly Rate
Ending Hourly Rate
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