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Algonquin Nurses PRN is
an equal opportunity employer and will not discriminate on the basis
of handicap, veterans status, race, color, creed, religion, national
origin, or ancestry, age or sex as provided by law.
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First Name
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Last Name
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Phone |
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State
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Zip
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Email Address:
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Today's Date:
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Social Security Number:
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If Under 18, Please Indicate
Date of Birth:
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Position Applying For:
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Available to Work (Mark All
Applicable Boxes):
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Day
Evening
Night
Rotating
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Full Time
Part Time
Other
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Date Available to Work:
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Do you have a legal right to work and remain
in the US?
Yes
No
(proof of citizenship or
permanent resident alien status may be required after employment)
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Are you in any way limited in
your ability to carry out the assignments of the position for which
you applied and perform them in a safe manner?
Yes
No
If Yes, please explain.
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If you have been employed under
a last name other than the one you are currently using, please state
name.
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Please list your
former employers starting with the most recent position
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May we contact your
present employer?
Yes
No |
Company
Name |
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Supervisor's
Name |
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| Address |
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Phone |
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| City |
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State
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Zip
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| Date Started |
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Date Left
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Type of Business
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| Full Time
Part Time
Per Visit
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Salary
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| Reason For Leaving |
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| OK to Contact Supervisor? |
Yes
No
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Describe your job title,
responsibilities, and accomplishments:
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Company
Name |
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Supervisor's
Name |
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| Address |
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Phone |
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| City |
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State
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Zip
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| Date Started |
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Date Left
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Type of Business
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| Full Time
Part Time
Per Visit
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Salary
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| Reason For Leaving |
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| OK to Contact Supervisor? |
Yes
No
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Describe your job title,
responsibilities, and accomplishments:
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Company
Name |
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Supervisor's
Name |
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| Address |
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Phone |
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| City |
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State
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Zip
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| Date Started |
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Date Left
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Type of Business
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| Full Time
Part Time
Per Visit
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Salary
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| Reason For Leaving |
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| OK to Contact Supervisor? |
Yes
No
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Described your job title,
responsibilities, and accomplishments:
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| PERSONAL REFERENCES: (Name, Phone,
Relationship)
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Please review and send
In making application form employment:
- I certify that the information in
this application is true and complete for all practical
purposes. It may be verified by the facility or affiliate.
Should a position be offered and later it is found that
the information is significantly untrue, incomplete, or
misrepresented, I understand and agree that the facility
or its affiliates are relieved of all commitments, financial
or otherwise pertinent to employment, and that I am subject
to immediate discharge without recourse.
- I understand that an investigative
report may be made by a consumer reporting agency to include
information as to my character, general reputation, personal
characteristics, and mode of living, whichever may be applicable.
If such an investigative report is made, I understand that
I will receive notice that such report has been requested,
and that I will have the right to make written request
for a complete and accurate disclosure of additional information
concerning the nature and scope of the investigation.
- I understand and agree that if I
am offered employment by the facility, my employment will
be for no definite term and that either I, or the facility
will have the right to terminate the employment relationship
at any time, with or without cause, and with or without
notice. I also understand that this status can only
be altered by a written contract of employment which is
specific as to all material and is signed by me and the
Administrator of the facility.
- I understand, if I am an unlicensed
person who has direct patient contact, that the agency will
perform a criminal history check per State Regulations.
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Release:
By sending this application,
I hereby authorize any prior employers to provide
such information concerning my employment with them
as may be requested, and also authorize the Registrar/Placement
Office of all educational institutions attended to
release an official copy of my transcript and, if
available, faculty appraisals. I also authorize
any appropriate licensing board to release full information
concerning my license status and my license history.
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