Employment Application Form

Last Name:*

First Name:*

Middle Initial:

Other Names Previously Used:

Address:

City/State/Zip code:

D.O.B.

S.S.N:

E-mail *

Drivers License:

Phone (Day):

Phone (Night):

Fax

Pager

Are you a U.S. Citizen?

Yes

No

If no, please provide work authorization:

LICENSURE

State

Number

Expiration Date

CERTIFICATION

Check all that apply:

ACLS

Exp. Date

PALS

Exp. Date

CPR

Exp. Date

CNOR

Exp. Date

Have you ever been convicted of a crime other that a minor traffic violation?

Yes

No

Have you ever been convicted of a felony?

Yes

No

Have any disciplinary actions been taken against your nursing license?

Yes

No

Have you ever been named a defendant in a professional liability action?

Yes

No

If you responded “Yes” to any of the above, please attach a separate sheet with explanation

Applicant's Name*

EDUCATION

Name and Location of School

Month/Year Graduated

Degrees or Certifications

College

Graduate School

Other Schools (If Applicable)

DATE AVAILABLE:

Shifts:

Days (8hrs)

Evenings (12hrs)

Nights

Holidays

REFERENCES:

Three references are required. At least one reference should be a supervisor under whom you have worked.

Name

Office Address

Phone Number

EMPLOYMENT PROFILE:

Please indicate all of your employment for the past five (5) years starting with your most recent employer

Facility/Employer

Unit/Floor/Dept.

Street Address

City

State

Zip Code

Dates Employed: From

Dates Employed: To

Reason for leaving:

Position Held

Unit Specialty

Supervisor's Name & Title

Phone

Facility/Employer

Unit/Floor/Dept.

Street Address

City

State

Zip Code

Dates Employed: From

Dates Employed: To

Reason for leaving:

Position Held

Unit Specialty

Supervisor's Name & Title

Phone

Facility/Employer

Unit/Floor/Dept.

Street Address

City

State

Zip Code

Dates Employed: From

Dates Employed: To

Reason for leaving:

Position Held

Unit Specialty

Supervisor's Name & Title

Phone

EMERGENCY CONTACT INFORMATION

Name:

Address:

City/State/Zip code:

Phone:

Relationship:

RELEASE STATEMENT:

I hereby attest that the information provided is true, accurate, and complete to the best of my knowledge and that I am the individual completing this form.

I understand that falsification of information will be basis for disqualification or termination of employment.

I hereby authorize all my prior employers, the officials of all schools which I have attended or been associated with, all public officials, and any persons named above on this application to give any information regarding me, whether or not it is on their records, to Pace Medical Staffing, Inc.

I also authorize Pace Medical Staffing, Inc. to release this same information to their client institution and appropriate governmental and licensing entities.

The said employers, schools, public officials, and other persons and entities are released from all liabilities whatsoever for issuing this information.

I understand that drug and criminal background screening is a requirement and I agree to undergo such screening when requested.

Print name:*

Signature: *

Date