Other Name(s) Used
Home Telephone:
Mobile Telephone:
Referred By
Skill Level
Area of clinical experience & years in each area
Have you ever had any professional license suspended, censured, or revoked?
Have you ever been under investigation by any state board of nursing?
Have you ever been reported for any type of abuse or neglect to any agency?
Have you ever (a) been arrested by any law enforcement agency and (b) are you presently on probation or have you ever been on probation with any law enforcement agency in the past?
If yes, list date(s) & location(s)
Are you at least 18 years old?
If under 18, do you have a work permit?
Please list which hours, either 7A-7P or 7P to 7A, and days of the week you are available to work
Highest Grade Completed High School
College, Trade or Business School
Graduate Studies
High School Name, Address, Major Studies and Degree, Diploma or Certificate
College/University Name, Address, Major Studies and Degree, Diploma or Certificate
Vocational, Business, Other School Name, Address, Major Studies and Degree, Diploma or Certificate
What month, year and state did you pass initial state board examination?
List all states, past and present, that you have held or hold a professional license in (including license #)
For Clerical applicants only
Do you type?
If yes, Words per minute:
Computer Skills (Hardware/Software)
Start Date
Ending Date
Employer Name
Employer Address
Supervisor Name
Supervisor Phone #
Starting Salary
Ending Salary
Job Title
Reason for Leaving
Duties & Responsibilities
Start Date(1)
Ending Date(1)
Employer Name(1)
Employer Address(1)
Supervisor Name(1)
Supervisor Phone #(1)
Starting Salary(1)
Ending Salary(1)
Job Title(1)
Reason for Leaving(1)
Duties & Responsibilities(1)
Start Date(2)
Ending Date(2)
Employer Name(2)
Employer Address(2)
Supervisor Name(2)
Supervisor Phone #(2)
Starting Salary(2)
Ending Salary(2)
Job Title(2)
Reason for Leaving(2)
Duties & Responsibilities(2)
Start Date(3)
Ending Date(3)
Employer Name(3)
Employer Address(3)
Supervisor Name(3)
Supervisor Phone #(3)
Starting Salary(3)
Ending Salary(3)
Job Title(3)
Reason for Leaving(3)
Duties & Responsibilities(3)
May we contact your current employer?
Have you ever applied to us before?
Will you be able to perform the essential job functions you are applying for with or without reasonable accommodation?
Have you ever been convicted of a crime, excluding traffic misdemeanors and summary offenses, which has not been annulled, expunged or sealed by court? (A yes response does not automatically disqualify you from employment.)
The above information is true and correct. I understand that, in the event of my employment by the Company, I shall be subject to dismissal if any information that I have given in this application is false or misleading or if I have failed to give any information herein requested, regardless of the time elapsed after discovery. I authorize the Company to inquire into my educational, professional licensure and past employment history references as needed to research my qualifications and background for this position. I hereby give my consent to any former employer to provide information about me to Firstat. I will hold Firstat and my former employer harmless from any decision made on the basis that information. I further authorize Firstat to obtain any professional licensure information from any licensing agency regarding any past or current license, including but not limited to any disciplinary or investigative action from my past or present I understand that nothing in this employment application, the granting of an interview or my subsequent employment with the Company is intended to create an employment contract between myself and the Company under which my employment could be terminated only for cause. On the contrary I understand and agree that, if hired, my employment will be terminable at will and may be terminated by me or the Company at any time and for any reason. I understand that no person has any authority to enter into any agreement contrary to the foregoing. I understand that I am required to contact Firstat Nursing Services after the end of each assignment to request a new assignment, and that unemployment benefits may be denied for failure to do so. I also understand that my continued employment is contingent upon me providing and maintaining a current copy of my license, CPR card and current (within one year of being administered) TB for my personnel file at FIRSTAT NURSING SERVICES. I also understand that failure to keep nursing licensure and credentials current is considered willful neglect on my part. I hereby acknowledge that I have read and agree to the above statements.

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