Employment Application Form

Position Applying For: * RN LPN CNA PCA
Other:
Last Name *
First Name *
Maiden Name
Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Home Phone No. * - (###) - ### ####
Alternate Phone No. - (###) - ### ####
Work Phone No. - (###) - ### ####
Email *
May we call you at work? * Yes No
Best time to call : HH MM AM/PM
Can you, at the time of employment, submit verification of your legal right to work
in the United States? * Yes No
Verification and completion of the I-9 form must be submitted no later than three (3) business days after date of hire.
Number of hours per week desired: *
Date available to work: / MM / DD YYYY
Type of work: * Hospital NH Clinics Home Care
Will you be able to work overtime if required? * Yes No
Have you ever been discharged or resigned in lieu of discharge? * Yes No
If yes, Please explain:
Have you ever been convicted of a felony? * Yes No
If yes, Please explain:
EDUCATION
Educational levels are relevant for employment (applicable only to the extent required by law.)
High School
Name of school
Years Completed Circle/Enter
Diploma/Degree
Describe Course of Study or Major
Describe Special Training, Experience, Skills and Extra Activities
College/University Degree
Name of school
Years Completed Circle/Enter
Date of Degree / MM / DD YYYY
Diploma/Degree
Describe Course of Study or Major
Describe Special Training, Experience, Skills and Extra Activities
Graduate/Professional
Name of school
Date Completed / MM / DD YYYY
Diploma/Degree
Describe Course of Study or Major
Describe Special Training, Experience, Skills and Extra Activities
Trade/Correspondence
Name of school
Date Completed / MM / DD YYYY
Diploma/Degree
Describe Course of Study or Major
Describe Special Training, Experience, Skills and Extra Activities
EMPLOYMENT HISTORY
Experience (Start with Most Recent Employer) - may we contact your current employer? Yes No
Employer # 1
Company Name
Address
Phone No. - (###) - ### ####
Position Held
Supervisor
Responsibilities
Reason for Leaving
Dates Employed from / MM / DD YYYY
To / MM / DD YYYY
Pay Rate/Salary
Pay Rate/Salary
Begin
End
Employer # 2
Company Name
Address
Phone No. - (###) - ### ####
Position Held
Supervisor
Responsibilities
Reason for Leaving
Dates Employed from / MM / DD YYYY
To / MM / DD YYYY
Pay Rate/Salary
Pay Rate/Salary
Begin
End
Employer # 3
Company Name
Address
Phone No. - (###) - ### ####
Position Held
Supervisor
Responsibilities
Reason for Leaving
Dates Employed from / MM / DD YYYY
To / MM / DD YYYY
Pay Rate/Salary
Pay Rate/Salary
Begin
End
ACKNOWLEDGEMENT

In signing this application, I certify that I have read and fully understand the questions asked in this application and that all answers given by me are true, accurate, and complete. I also understand that the omission, concealment, or misrepresentation of any fact on this application or during any interview for employment may jeopardize my chances for employment and be cause for my immediate dismissal from employment.

I acknowledge that, as an employee of Bay Nursing, I will be assigned to temporarily assist clients of Bay Nursing. I am not assured that I will work for a particular client, or on particular days or hours/shifts, or even that I will be assigned to clients in a specific geographic area. In fact, I acknowledge that I may be assigned to work for different clients, at different dates/times/shifts, and at different locales. I agree that as long as I am offered employment at the same wage rate and within 35 miles of my home, I have been offered equivalent employment. If I decline such an assignment, then I agree that I have voluntarily quit my employment with Bay Nursing.
* I HAVE READ THE ABOVE AND FULLY UNDERSTAND IT.
Applicant Signature
Date / MM / DD YYYY
I acknowledge that I have read and agree to these terms.

Employment Application Form

Employment Application Form

Verification and completion of the I-9 form must be submitted no later than three (3) business days after date of hire.

EDUCATION

High School

College/University Degree

Graduate/Professional

Trade/Correspondence

EMPLOYMENT HISTORY

Employer # 1

Employer # 2

Employer # 3

ACKNOWLEDGEMENT

I acknowledge that I have read and agree to these terms.