Professional Resources for Nurses, Inc. Employee Application Name ___________________________________________________________ (Last) (First) (MI) Current Address ________________________________________________ (Number) (Street) (Apt.) ________________________________________________ (City) (State) (Zip) Phone ( )____________ Cell ( )______________ Best time to call ________________________ E-mail address____________________________ Social Security Number ___________________ Emergency Contact Name & Phone Number __________________________ ________________________________________________________________ IF YOU ANSWER "YES" TO ANY OF THE FOLLOWING QUESTIONS, PLEASE DESCRIBE THE INCIDENT ON A SEPARATE PIECE OF PAPER Has you license ever been under investigation? _____Yes _____No Have you ever been convicted of a felony? _____Yes _____No LICENSURE INFORMATION (PLEASE ENCLOSE PHOTOCOPIES OF YOU NURSING LICENSE(S)) __________________________________ | STATE | EXP DATE | |________________|_________________| | | | |________________|_________________| | | | |________________|_________________| | | | |________________|_________________| EDUCATION INFORMATION (PLEASE BEGIN WITH LAST COLLEGE AND DEGREE ATTAINED AND INCLUDE ANY HEALTH RELATED VOCATIONAL TRAINING _________________________________________________________________ |YEAR| NAME & ADDRESS OF COLLEGE/UNIVERSITY | DEGREE | |GRAD|___________________________________________|________________| | | | | |____|___________________________________________|________________| | | | | |____|___________________________________________|________________| | | | | |____|___________________________________________|________________| Please list any areas in which you have current ANA certification: ____________________________________________________________________ ____________________________________________________________________ Areas of specialty 1.______________________________________________ 2. _____________________________________________ CPR Expiration date __________________ (Please send copy of card or roster) EMPLOYMENT PROFILE PLEASE LIST YOUR EMPLOYERS BY THE MOST CURRENT EMPLOYER FIRST Name of employer ___________________________________________________ Address ____________________________ City ___________State _________ Zip Code __________ Date of Hire _________to_____________Job title _____________________ Name of supervisor __________________________Title _________________ Description of work ________________________________________________ ____________________________________________________________________ Reason for leaving _________________________________________________ ____________________________________________________________________ ******************************************************************** Name of employer ___________________________________________________ Address ____________________________ City ___________State _________ Zip Code __________ Date of Hire _________to_____________Job title _____________________ Name of supervisor __________________________Title _________________ Description of work ________________________________________________ ____________________________________________________________________ Reason for leaving _________________________________________________ ____________________________________________________________________ ******************************************************************** Name of employer ___________________________________________________ Address ____________________________ City ___________State _________ Zip __________ Date of Hire _________to_____________ Job title _______________ Name of supervisor __________________________Title _________________ Description of work ________________________________________________ ____________________________________________________________________ Reason for leaving _________________________________________________ ____________________________________________________________________ ******************************************************************** I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and pertinent information concerning they may have, personal or otherwise and release the company from all liability for any damage that may result from utilization of such information. Signature _______________________________________ Date ______________