Choose your Profession:
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RN
LPN
CNA
CST
Diagnostic Imaging Professional
Physical Therapist
Respiratory Therapist |
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License No.:
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Last Name: (required)
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First Name: (required)
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Middle Initial:
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Social Security Number:
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Phone Number: (required)
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E-Mail Address:
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Permanent Address:
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City:
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State/Province:
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Zip/Postal Code:
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Permanent Phone:
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Current Address:
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City:
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State/Province:
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Zip/Postal Code:
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Present Phone:
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Will be at this location until:
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Best time of day to reach you:
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| Additional Information: |
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Referral Source:
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Other (Please Specify):
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Region State City Preferences:
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Have you ever applied to us before?
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yes
no |
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If so, when?:
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Desired length of assignment:
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Date you can start:
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Geographic Preference:
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Shift Preference:
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Certifications:
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Have you ever had any disciplinary action taken against
any of your licenses?
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yes
no |
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Have you ever been named as a defendant in a malpractice
claim?
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yes
no |
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Have you ever been convicted of a felony?
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yes
no |
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Do you hold a nursing license under any other name?
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yes
no |
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If so, please list name:
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Current Driver's License#
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State:
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Exp. Date:
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Do you have the legal right to work in the United States
and do you have documentation of that right?
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yes
no |
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Related Courses/Certification (i.e., Chemotherapy, EKG,
Balloon Pump, etc.)
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| Employment History |
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May we contact your present employer?
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yes
no |
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May we contact your previous employers?
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yes
no |
| Most Recent |
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Hospital:
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City:
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State:
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Date employed:
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from
to
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Position held:
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Specialty unit(s) worked:
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Shift:
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Reason for leaving:
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Average patient ratio:
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Number of beds in unit:
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Number of beds in hospital:
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Was this a travel assignment?
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yes
no |
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Which agency?
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Type of nursing:
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Did you have a supervisory role?
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Immediate supervisor:
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Phone:
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| Second Most Recent |
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Hospital:
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City:
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State:
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Date employed:
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from
to
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Position held:
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Specialty unit(s) worked:
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Shift:
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Reason for leaving:
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Average patient ratio:
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Number of beds in unit:
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Number of beds in hospital:
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Was this a travel assignment?
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yes
no |
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Which agency?
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Type of nursing:
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Did you have a supervisory role?
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Immediate supervisor:
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Phone:
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| EDUCATIONAL BACKGROUND |
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College or University:
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College or University City:
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College or University State:
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Graduated?
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yes
no |
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Graduation Year
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Diplomas, Degrees Received:
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Nursing School or University:
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Graduated?
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yes
no |
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Graduation Year
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Diplomas, Degrees Received:
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Graduate School:
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Graduated?
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yes
no |
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Graduation Year
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Diplomas, Degrees Received:
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| List any other skills or attributes which you feel make
you exceptionally qualified for a position with this company: |
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| 2 PROFESSIONAL
REFERENCES |
| Name 1 |
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| Phone Number |
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| Name 2 |
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| Phone Number |
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| EMERGENCY CONTACT |
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Name:
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Relation:
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Address:
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City:
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State:
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Home Phone:
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Work Phone:
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| EMPLOYMENT WAIVER |
| I understand and agree that:
This is
an application for employment and in no way a contract.
Job duties and hours may vary from the original preference.
Any withholding
of information, making false statements or misrepresentation
of fact on this application could result in rejection for
employment, or, if employed, termination of employment.
A medical
examination, as stipulated by Apex Healthcare Solutions
is required for employment. Any offer of employment is contingent
upon the results of the examination in consideration of
the Americans with Disabilities Act guidelines.
I authorize
and request the persons, schools, law enforcement agencies,
and other organizations or employers named in this application
(except as noted) to provide Apex Healthcare Solutions with
any relevant information that may concern employment. I
understand that a criminal background check and pre-employment
drug testing is part of the Apex Healthcare Solutions employment
process. I understand that the results of the criminal background
check , pre-employment drug screen and health forms may
be made available to Apex Healthcare Solutions clients before
starting an assignment as a Apex Healthcare Solutions employee.
I waive the right to review any references received.
Should
a job offer be made, proof of employability and identification,
as required by the Immigration Reform and Control Act of
1986, will be required prior to the first day of work.
I agree
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