* = Required Information

Personal Data

Email Address: *		Today's Date

Last Name *	First Name *	Middle *	SSN

Home Address *	City *	State	Zip *

Home Phone *	Cell Phone	Pager

DOB *

Emergency Contact Information

Name of Emergency Contact *	Relation *	Emergency Telephone Number *

Job Information

Position (Job Class) Applying for:
RN PT LP/VN CNA OT PTA Clerical Other
Date Available:


Work Experience/Skills

Please list the number of years you have experience in each area (min 1 year exp.) and are clinically competent to work:

Burn	ENT	Pediatrics	Detox/Drug Rehab
L & D	Rehab	Telemetry	Post Partum
MICU	Nursery	Psychiatry	Orthopedics
NICU	Dialysis	Stepdown	Mother/Baby
PACU	Geriatric	Oncology	Recovery Room
SICU	Pedi ICU	Neurology	Operating Room
CCU	Med/Surg	Open Heart	Emergency Room
Other	Other	Other	Other

Previous Facility Types Worked: Check All That Apply -
Hospital	Hospice	Nursing Home	Rehab
Private Duty	Assisted Living / Residential Treatment

Language Skills: Other than English, please check any other languages you speak -
Spanish	French	German	Other

Check the type of assignment you are available for:
Full-time	Part-time	Contract	Travel

Check the days of the week you are available to work:
Monday	Tuesday	Wednesday	Thursday
Friday	Saturday	Sunday
Holidays available to work:

License Type	License/Certification #	State	Expiration Date

Has your professional license ever been suspended, revoked or under investigation?	YesNo
If Yes, Please explain:

Certifications: Check all applicable certifications and enter expiration date:
ACLS	Expiration Date:	Other	Expiration Date:
BCLS	Expiration Date:	IV	Expiration Date:
CPR	Expiration Date:	NALS	Expiration Date:

Work Experience: List all of your work experience beginning with your most recent job. You will be asked to explain all gaps in employment. Attach additional sheet(s) if necessary.

Facility/Employer Name

Address

City	State	Zip	Country

Number of Beds in Unit:		In Hospital:

Describe duties and specialty areas:

Pay Rate/Salary:	Hourly	Yearly
Reason for leaving:

Are your employment records listed under another name? YesNo
If yes, what name?
Date Employed	From:	To:
Title
Unit
Name of Current Immediate Supervisor
Telephone #
May We Contact:	YesNo
If no, why?
If this was a travel assignment, name of agency

Supervisory Experience:	YesNo
How often?


Facility/Employer Name

Address

City	State	Zip	Country

Number of Beds in Unit:		In Hospital:

Describe duties and specialty areas:

Pay Rate/Salary:	Hourly	Yearly
Reason for leaving:

Are your employment records listed under another name? YesNo
If yes, what name?
Date Employed	From:	To:
Title
Unit
Name of Current Immediate Supervisor
Telephone #
May We Contact:	YesNo
If no, why?
If this was a travel assignment, name of agency

Supervisory Experience:	YesNo
How often?


Facility/Employer Name

Address

City	State	Zip	Country

Number of Beds in Unit:		In Hospital:

Describe duties and specialty areas:

Pay Rate/Salary:	Hourly	Yearly
Reason for leaving:

Are your employment records listed under another name? YesNo
If yes, what name?
Date Employed	From:	To:
Title
Unit
Name of Current Immediate Supervisor
Telephone #
May We Contact:	YesNo
If no, why?
If this was a travel assignment, name of agency

Supervisory Experience:	YesNo
How often?

Please list any other work related information you think would be helpful to us in considering you for employment, such as specialized training, certifications, additional work experience, etc.

Additional Information:
1. Are you legally authorized to work in the USA?	YesNo
2. Have you ever been convicted of a felony?	YesNo
3. Can you pass a pre-employment drug test?	YesNo
4. How were you referred to?	Newspaper Trade Publication Job Fair/Open House Internet Site Company Employee - Name:

I understand that I must report all accidents to my immediate supervisor and to - - No MATTER HOW SLIGHT. Yes
I also understand that I must wear all required personal protection equipment (PPE). Yes
The penalty for not wearing PPE is disciplinary action, up to and including termination.

Applicant's Name

ACKNOWLEDGMENT (Please read carefully)

In signing this application, I certify that I have read and fully understand the questions asked in this application and that all answers given by me are true, accurate, and complete. I also understand that the omission, concealment, or misrepresentation of any fact on this application or during any interview for employment may jeopardize my chances for employment and be cause for my immediate dismissal from employment.
I give permission to use any information in this application to enable it and its agents to verify the information contained in this application I also authorize present and former employers, educational institutions I have attended, credit agencies, all references, and any other persons to answer all questions asked by with regard to any of the subjects covered by this application. I also understand that in connection with my application for employment or my employment, may conduct a criminal background investigation and that my employment may be contingent on the results of such investigation. I release, its agents, and all affiliated entities, as well as any person or situation that provides any information about me, from any and all liability whatsoever resulting from any such investigation or the disclosure of such information.
In consideration of my employment and of my being considered for employment by, I agree to abide by all rules and regulations, which I understand are subject to change at any time for any reason without prior notice. I also understand that if employed, I will be an employee at will and employed for no definite period of time. I understand that either or I can terminate my employment at any time, with or without cause and with or without advance notice. I further understand that no communication, whether oral or written, by any representative of, at any time, can constitute a contract of employment. No representative or agent of, has the authority to enter into any agreement for employment for any specific period of time or to make any agreement contrary to the foregoing.
I am willing to submit to a physical examination, including the analysis for the detection of the use of unlawful drugs or substances in accordance with the applicable laws. If I receive an offer of employment I agree that my continued employment may be contingent on the results.
I understand that is not involved in the day-to-day supervision or decision concerning patient care or dentistry. This remains with the Professional as part of the Professional�s practice. The Professional fully indemnifies against any and all liability and responsibility associated with his or her professional duties. The Professional maintains his or her license as required by law, professional liability coverage and other responsibilities as found under state prime contract law.

I DO AFFIRM THAT I DO NOT HAVE ANY CRIMINAL CHARGES IN OR OUTSIDE VIRGINIA.

I HAVE READ THE ABOVE AND FULLY UNDERSTAND IT.

Applicant's Name *

Date