EMPLOYMENT APPLICATION

FOR NURSES

Application must be completed with current information. If information is not available, please answer N/A. The information is relied upon when completing applications with State and Federal Government Agencies. 

 

Name:

 

Last name:      

First:      

Other Names:      

 

 

 

Permanent Address:

 

 

 

Street Address:      

 

City:      

State:      

Country:      

Postal Code:      

 

 

 

Mailing Address (If Different than Permanent Address):

 

Mailing Address:      

 

City:      

State:      

Country:      

Postal Code:      

 

 

 

Telephone Number (With Country Code and City Code):      

Fax Number (With Country Code and City Code):      

E-Mail Address:      

Mobile Number (With Country Code and City Code):      

Age:      

Marital Status (single, married):      

Gender: Male             Female

Social Security # (if any):      

 

 

Passport Information:

 

Date of Birth: (mm/dd/yyyy):      

City / Province / Country of birth:      

Nationality:      

Country of Legal Residence:      

Country of Citizenship:      

Passport number:      

Issue date:      

Expire Date:      

 

Visa Information:

 

In what country do you intend to apply for your visa?      

(Application in your country of citizenship is often required and always preferable.)

Have you ever visited the US?     Yes              No

If yes,

Type of Visa Held:      

Purpose of Visit:      

Date of Entry (mm/dd/yyyy):      

Date you actually exited the US (mm/dd/yyyy):      

 

 

Have you ever been deported from the US, had a visa refused or overstayed in the US at anytime?            Yes              No

If Yes, please give details:      

 

Have you ever traveled abroad (excluded United States)?

If yes,

What country?

Type of Visa Held:      

Purpose of Visit:      

Date of Entry (mm/dd/yyyy):      

Date you actually exited this country (mm/dd/yyyy):      

 

What country?

Type of Visa Held:      

Purpose of Visit:      

Date of Entry (mm/dd/yyyy):      

Date you actually exited this country (mm/dd/yyyy):      

 

Other:

 

Education: (Including Professional Nursing Education; Start with current school and list backward.)

Additional Certificates/Programs:

Name of school and address:     

Start Date (month/year):      

End Date (month/year):      

Major field(s) of Study:      

License or Certificate:      

 

Education (continued) : (Including Professional Nursing Education; Start with current school and list backward.)

 

Name of school and address:      

Start Date (month/year):      

End Date (month/year):      

Major field(s) of Study:      

License or Certificate:      

 

Name of school and address:      

Start Date (month/year):      

End Date (month/year):      

Major field(s) of Study:      

License or Certificate:      

 

 

University Programs:

Name of school and address:      

Start Date (month/year):      

End Date (month/year):      

Major field(s) of Study:      

Degrees or Certificates:      

 

College Programs:

Name of school and address:      

Start Date (month/year):      

End Date (month/year):      

Major field(s) of Study:      

Degrees or Certificates:      

 

High/Secondary School:

Name of school and address:      

Start Date (month/year):      

End Date (month/year):      

Major field(s) of Study:      

Degrees or Certificates:      

Work Experience:

Describe your Present Nursing Employment:

Name and Address of Employer:      

Start Date (month/year):      

End Date (month/year):      

Job Title or Position:       

1. Nursing Specialty:                  Years of experience:                  As of (indicate date):      

2. Nursing Specialty:                  Years of experience:                  As of (indicate date):      

3. Nursing Specialty:                  Years of experience:                  As of (indicate date):      

Number of beds: Unit/Ward:                      Hospital:                                                                                Average Patient Ratio:      

Previous Employment:

Name and Address of Employer:      

Start Date (month/year):      

End Date (month/year):      

Job Title or Position:      

1. Nursing Specialty:                  Years of experience:                  As of (indicate date):      

2. Nursing Specialty:                  Years of experience:                  As of (indicate date):      

3. Nursing Specialty:                  Years of experience:                  As of (indicate date):      

Number of beds: Unit/Ward:                      Hospital:                                                                                Average Patient Ratio:      

Reason for leaving:      

 

Name and Address of Employer:      

Start Date (month/year):      

End Date (month/year):      

Job Title or Position:      

1. Nursing Specialty:                  Years of experience:                  As of (indicate date):      

2. Nursing Specialty:                  Years of experience:                  As of (indicate date):      

3. Nursing Specialty:                  Years of experience:                  As of (indicate date):      

Number of beds: Unit/Ward:                      Hospital:                                                                                Average Patient Ratio:      

Reason for leaving:      

Reason for leaving:


Work Experience (continued):

Name and Address of Employer:      

Start Date (month/year):      

End Date (month/year):      

Job Title or Position:      

1. Nursing Specialty:                  Years of experience:                  As of (indicate date):      

2. Nursing Specialty:                  Years of experience:                  As of (indicate date):      

3. Nursing Specialty:                  Years of experience:                  As of (indicate date):      

Number of beds: Unit/Ward:                      Hospital:                                                                                Average Patient Ratio:      

Reason for leaving:      

 

Clinical Experience:

Critical Care                                         

 Cardiac                                Years of experience:                              As of (indicate date)      

 Respiratory               Years of experience:                              As of (indicate date)      

 Neurology                 Years of experience:                              As of (indicate date)      

 Gastrointestinal                    Years of experience:                              As of (indicate date)      

 Renal                                   Years of experience:                              As of (indicate date)      

 Vascular                              Years of experience:                              As of (indicate date)      

Other:

 Burns                                   Years of experience:                  As of (indicate date)      

 Blood Glucose

 Monitoring                Years of experience:                  As of (indicate date)      

 Multiple System

Failure                          Years of experience:                  As of (indicate date)      

 Chemotherapy                      Years of experience:                  As of (indicate date)      

 

 AIDS                                    Years of experience:                  As of (indicate date)      

 HIV                          Years of experience:                  As of (indicate date)      

 

 

 Medication Administration                  Years of experience:                  As of (indicate date)      

 Orthopedic                                       Years of experience:                  As of (indicate date)      

 Gynecology                                      Years of experience:                  As of (indicate date)      

 Emergency Department                     Years of experience:                  As of (indicate date)      

 Maternal/Neonatal                             Years of experience:                  As of (indicate date)      

 Medical/Surgical                                                                                                                               Years of experience:                                      As of (indicate date)      

 Neonatal Intensive Care                     Years of experience:                  As of (indicate date)      

 Operating Room                                Years of experience:                  As of (indicate date)      

 Pediatric ICU                                                Years of experience:                  As of (indicate date)      

 Psychiatric                                       Years of experience:                  As of (indicate date)      

 Stepdown ICU/Telemetry                   Years of experience:                  As of (indicate date)      

 Telemetry                                         Years of experience:                  As of (indicate date)      

Clinical Experience (continued):

List specific equipment, which you can work with independently:

     

     

     

 

Age Specific Practice Criteria: (Check each age group for which you have expertise in providing age-appropriate nursing care.)
  1.  Newborn/Neonate (Birth – 30 days)
  2.  Infant (30 days – 1 year)
  3.  Toddler (1 – 3 years)
  4.  Preschooler (3 – 5 years)
  5.  School Age Children (5 – 12 years)
  6.  Adolescents (12 – 18 years)
  7.  Young Adults (18 – 39 years)
  8.  Middle Adults (39 – 64 years)
  9.  Older Adults (64+)

 

Licensure:

CGFNS Examination taken: Yes No

  If Yes, indicate date (month/day/year):                       Score:      

NCLEX Examination taken: Yes No

  If Yes, indicate date (month/day/year):               Score:      

Do you hold a US RN License? Yes No

              If Yes, please provide the following information:

              State or Territory:                    Date of Exam:                                                                

License #, if Granted:        License Expiration Date:      

 

Has your nursing license ever been investigated, suspended or revoked? Yes No

 

              If Yes, please provide the details for all applicable jurisdictions and final outcome below:

     

     

     

 

Do you have any malpractice or negligence suits pending? Yes No

              If Yes, please detail the situation and its current status below:

     

     

Licensure (continued):

Have you ever been convicted of a crime? Yes No

              If Yes, please provide the circumstances, dates and final outcome below:

     

     

     

 

English Language:

 

Spoken:

 Excellent

 Good

 Fair

 Poor

Written:

 Excellent

 Good

 Fair

 Poor

Listened and Understood:

 Excellent

 Good

 Fair

 Poor

 

TOEFL Examination taken: Yes No

  If Yes, indicate date (month/day/year):                           Score:      

TWE Examination taken: Yes No

  If Yes, indicate date (month/day/year):                           Score:      

TSE Examination taken: Yes No

  If Yes, indicate date (month/day/year):                           Score:      

What other language(s) do you speak/write?      

Emergency Contact Information:

If your family members applying with you, please provide the following information:

Spouse Information:

Surname:                                  First:                                         Other Names:      

If wife, state Maiden Name:      

Date of Birth:      

Place of Birth:                            City or Town:                             Country:      

Current Address:      

Spouse’s Occupation:      

Date of Marriage:                       Place of Marriage:      

Passport Information:      

Spouse Information (continued):

 

Immigration History (if any):      

Social Security # (if any):      

 

Children Information:

Surname:                                  First:                             Other Names:      

Date of Birth:      

Place of Birth:                            City or Town:                             Country:      

Surname:                                  First:                                         Other Names:      

Date of Birth:      

Place of Birth:                            City or Town:                             Country:      

 

 

The statements made in this application are true to best of my knowledge and I understand that my falsification will be the basis for disqualification of employment or termination of services.

Applicant’s Typed Name:      

Applicant’s Signature: _____________________________________________________

Date: