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Today's Date (mm/dd/yyyy):
*
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Date Available for Work (mm/dd/yyyy):
*
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First Name:
*
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MiddleInitial:
*
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Last Name:
*
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E-Mail Address:
*
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Please enter e-mail address again (required)
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Address:
*
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City:
*
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State:
*
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Zip:
*
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Cell Phone:
*
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Other Phone:
*
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Eligible to Work:
*
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Yes
No
Can you provide eligibility to work in the United States?
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Type of Licensure:
*
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RN
LPN
CNA
Other
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Other type of license:
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Shift Preference - Days:
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Yes |
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Shift Preference - Evenings:
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Yes |
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Shift Preference - Nocs:
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Yes |
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Shift Preference - Other:
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(doubles, 12s, ...)
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Day of Week Preferences:
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Monday |
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Tuesday |
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Wednesday |
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Thursday |
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Friday |
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Saturday |
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Sunday |
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Late Calls:
*
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Yes
No
Are you available for late calls?
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Travel Distance:
*
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How far are you willing to travel for shifts?
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Referred By:
*
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Investigated:
*
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Yes
No
Has your license or certification ever been under investigation?
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Explanation:
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If you have been investigated, please explain.
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Felony Conviction:
*
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Yes
No
Have you ever been convicted of a felony?
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Certify Information:
*
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Agree
I certify that the information in this application is accurate, current and complete. I understand that misstatements or omissions may result in disqualification from further consideration or termination.
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Authorize:
*
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Agree
I authorize PEAK NURSING TEAM, INC to disclose this application in addition to any information about me obtained through reference checks or during the course of the interview process for state, federal, contractual or accreditation audit information. I authorize PEAK NURSING TEAM, INC to investigate my employment history, credentials and to obtain any relevant information including a criminal-background-check. I authorize PEAK NURSING TEAM, INC to disclose any of my performance appraisal, skills tests or disciplinary records for the purposes stated above. I release PEAK NURSING TEAM, INC and any individual or entity providing information to PEAK NURSING TEAM, INC from all liability for any damages from the disclosure of this information.
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Understand Market Issues:
*
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Agree
I understand that in the event I become employed by PEAK NURSING TEAM, INC, my work assignments, schedules and/or work locations are subject to change according to market demands and the need of the clients of PEAK NURSING TEAM, INC.
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Understand Eligibility Issues:
*
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Agree
I understand that in the event I leave PEAK NURSING TEAM, INC, I am not eligible for employment within Peak Nursing's contract facilities for 90 days.
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| * = Required field |
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