Nightingale Full Application

Use the form below to register for permanent employment or consulting and subcontracting assignments. All information you send to us will be held in the strictest confidence. Under no circumstance will representation be made on your behalf without your prior authorization.

General Information * First Name *Middle * Last Name Preferred Name

* Permanent Tax Address * City * State/Province * Postal Code

* Email * Re-enter Email

Detailed Information Social Security Number Birthdate mm-dd-yyyy Available After (today) mm-dd-yyyy

Are you authorized to work in the US?

Telephone Numbers * Main Cell Assignment

Education School 1 City State Graduation Date Diploma/Degree Received

School 2 City State Graduation Date Diploma/Degree Received

Licensure * Specialty

*Please list all states in which you have been licensed (Include both active and inactive)
Hold Ctrl to select multiple states

Check here if you have a compact license.

Please list states you are currently licensed in

State Expiration Date

Certifications * Has your license or certification ever been investigated, suspended, or revoked?

If yes, please give explanation and final outcome.

* Are your CEU's up to date?

* Charting Software/EMR that you have used Hold Ctrl to select multiple

Do you have VetPro Experience in the past 7 years?

Do you have the following certifications and when do they expire?

CPR/BCLS Expiration Date mm-dd-yyyy

ACLS Expiration Date mm-dd-yyyy

NRP Expiration Date mm-dd-yyyy

PALS Expiration Date mm-dd-yyyy

Fetal Monitoring Expiration Date mm-dd-yyyy

Advanced Fetal Monitoring Expiration Date mm-dd-yyyy

ENPC Expiration Date mm-dd-yyyy

TNCC Expiration Date mm-dd-yyyy

Other Certification Expiration Date mm-dd-yyyy

* Do you have a latex sensitivity?

* Have you ever been convicted of a crime other than a minor traffic violation (including any dispositions of adjudication withheld)?

If yes, please give explanation.

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

* Can you submit verification of legal right to work in the U.S. if requested?

Previous Employment - Most Recent Employer First Please include your previous eight employers.

Employer * Hospital Name * City * State

* Employed From * Employed To * Specialty * Facility Setting

Supervisor Supervisor Phone

* Job Responsibilities * Reason for Leaving

Number of Beds in Unit Number of Beds in Hospital Average Patient Ratio

* Was this a Travel Assignment? * With which travel company or agency?

Was this a Teaching Hospital? Was this a Trauma Hospital? * Do you have charge experience? * Hourly Pay Rate

Add an additional employer

References All references must be from former managers.

Reference 1 Name Reference 1 Phone Position Hospital

Reference 2 Name Reference 2 Phone Position Hospital

Reference 3 Name Reference 3 Phone Position Hospital

Reference 4 Name Reference 4 Phone Position Hospital

Emergency Contact *Name *Relationship *Phone Number

Street Address City State Zip

Referral Information Were you referred to Nightingale Nurses?

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