U.S.

Nurses Incorporated
APPLICATION FOR EMPLOYMENT
PRE-EMPLOYMENT SCREENING IS REQUIRED Applications are considered for all positions without regard to race, color, religion, sex, national origin, age, maritime/veteran status, or disability. PERSONAL INFORMATION

FIRST NAME: LAST NAME: ADDRESS:

MIDDLE INITIAL:

CITY: SOCIAL SECURITY NUMBER: E-MAIL ADDRESS: DAYTIME TELEPHONE: EVENING TELEPHONE: CELL PHONE:

STATE:

ZIP:

EDUCATION HIGH SCHOOL: ADDRESS:

CITY:
COUNTRY:

STATE:
PROVINCE:

ZIP:

MAJOR: DID YOU GRADUATE? YES NO YEARS COMPLETED: DEGREE TYPE:

APPLICATION FOR EMPLOYMENT (Page 2)
COLLEGE / UNIVERSITY: ADDRESS:

CITY:
COUNTRY:

STATE:
PROVINCE:

ZIP:

MAJOR: DID YOU GRADUATE? YES NO YEARS COMPLETED: DEGREE TYPE:

GRADUATE / PROFESSIONAL: ADDRESS:

CITY:
COUNTRY:

STATE:
PROVINCE:

ZIP:

MAJOR: DID YOU GRADUATE? YES NO YEARS COMPLETED: DEGREE TYPE:

OTHER EDUCATION: ADDRESS:

CITY:
COUNTRY:

STATE:
PROVINCE:

ZIP:

MAJOR: DID YOU GRADUATE? YES NO YEARS COMPLETED: DEGREE TYPE:

APPLICATION FOR EMPLOYMENT (Page 3)
HONORS & AWARDS:

SKILLS / EXPERIENCE:
Describe Specialized Training, Apprenticeship, Skills with number of years experience. Describe any extra-curricular activities.

ADDITIONAL INFORMATION:
Please provide any additional information you would like considered with your application, particularly anything you believe would be helpful to us in considering you for the position.

LANGUAGE PROFICIENCY:
The primary requirement of most positions is English. Please indicate any additional languages you speak, read, or write.

LICENSES
Professional Licensure (please list Dates of Issue and Expiration in DD/MM/YY format): License/Ceritifcation State License Number Date Issued Date Expires Temporary?

License(s) applied for (state/country) License: License: License: State: State: State: Country: Country: Country:

APPLICATION FOR EMPLOYMENT (Page 4)
WORK HISTORY Starting with your PRESENT or LAST employer, please give your employment history, military, and other relevant work/volunteer experience within the last 10 years. Periods of unemployment must be explained in the Summary section. Employer: Street Address: City: State: Zip: Telephone Number: Job Title: Employed From: Starting salary: Ending salary: Supervisor: May we contact this employer for a reference? Principal Work Performed: Reasong for leaving: Yes No To:

Employer: Street Address: City: State: Zip: Telephone Number: Job Title: Employed From: Starting salary: Ending salary: Supervisor: May we contact this employer for a reference? Principal Work Performed: Reasong for leaving: Yes No To:

APPLICATION FOR EMPLOYMENT (Page 5)
Employer: Street Address: City: State: Zip: Telephone Number: Job Title: Employed From: Starting salary: Ending salary: Supervisor: May we contact this employer for a reference? Principal Work Performed: Reasong for leaving: Yes No To:

Employer: Street Address: City: State: Zip: Telephone Number: Job Title: Employed From: Starting salary: Ending salary: Supervisor: May we contact this employer for a reference? Principal Work Performed: Reasong for leaving: Yes No To:

APPLICATION FOR EMPLOYMENT (Page 6)
PERSONAL REFERENCES Please give three (3) references (DO NOT list relatives or previous employers). Name: Phone Number: Address: Relationship:

ADDITIONAL INFORMATION Minimum Salary Requirement: On what date are you available for work?: How did you find out about this position?: If you were referred by a current employee, please enter their name and department: Do you have any relatives currently employed here? If “yes,” please list their name(s) and department(s): What job status would you accept? What shift would you accept? Full-Time Part-Time 1st 7am-7pm Per Diem Temporary 2nd 7pm-7am YES NO

Weekend 3rd

PLEASE ANSWER ALL OF THE FOLLOWING QUESTIONS: Can you furnish a work permit if you are under 18? Are you prevented lawfully from becoming employed in this country because of Visa or immigration status? Can you travel if a job requires it? Have you ever been employed here or at another facility of our organization? If “yes,” please give the dates of your employment: From: To: YES YES NO NO YES NO

YES YES YES

NO NO NO

Are you on a lay-off and subject to recall? Have you filed an application here before? If “yes,” please give the date of your most recent application:

Have you ever been convicted of a crime? If “yes,” please explain:

YES

NO

APPLICATION FOR EMPLOYMENT (Page 7)
Are you able to perform all the functions of the job for which you are applying, with or without accommodations? YES NO

If you indicated you can perform all the functions with an accommodation, please explain how you would perform the tasks and with what accommodations:

(END)

U.S. Nurses Incorporated
Applicant’s Certification & Agreement (Please read carefully & sign upon completion)
In consideration of being employed, I understand and agree that: 1. 2. If I misrepresent or deliberately leave out a fact in my application, I may be refused employment or, if employed, I may be terminated. The employer has my authorization to thoroughly investigate my work and personal and credit history and I hereby consent to take any test, whenever the employer deems it necessary in any employer investigation. I will hold no person, corporation, or organization liable for giving or receiving information in such investigation. If employed, I may terminate my employment at any time without notice or cause, and the employer may terminate or modify the employment relationship at any time without notice or cause. In consideration of my employment, I agree to conform to the rules and regulations of the employer, and I understand that no department head or representative of the employer, other than the President of the Company, has any authority to enter into any agreement, oral or written, for employment for any specified period of time or to make any agreement or assurances to the contrary of this policy. Any doctor, hospital, or testing laboratory has my consent to conduct medical or drug tests on me, and I hereby give my consent to having all information released for the employer to determine my abilities to perform job duties now or in the future. I also give my consent to physical searches of myself and my briefcase, lunch box, car, locker, or any packages or purse I have while on the employer’s premises whether or not I have a lock on such items. The needs of the employer may make the following conditions mandatory: overtime, shift work, rotating work schedule, or a work schedule other than Monday through Friday. I accept these conditions of employment. The employer is an equal-opportunity employer. The employer does not discriminate in employment and no question on my employment application is used for the purpose of limiting or excluding any applicant’s consideration for employment on a basis prohibited by local, state, or federal law. If employed, I understand that my employment is for no definite period of time, and if terminated, the employer is liable only for the wages or salary earned as of the date of termination. I understand that the employer requires all staff to report sanction, convictions, suspensions, censures, or revocation (“sanction”) action taken against them by federal, state, local, or other professional entities. These sanctions may include but are not limited to infractions against professional licensure, criminal history of convictions, history of child abuse, managed care organizations, etc. This application is current and active only for six months. At the conclusion of this time, if I have not had any contact from the employer and still wish to be considered for employment, it will be necessary for me to fill out a new application. If employed, I understand that I must abide by the Company’s established Service Excellence standards and realize that Service Excellence is a priority of the Company.

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Should you be called for an interview, you will be asked to read & sign this Certification & Agreement

U.S. Nurses Incorporated
I have read and agree to the previous terms, and hereby certify that the facts I have provided in my employment application are true and complete.
PRINTED NAME:

SIGNATURE:

DATE: