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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.

First Name

Last Name

Address Phone
City

State

Zip

Email Address:

Today's Date:

Social Security Number:
If Under 18, Please Indicate Date of Birth:

Position Applying For:

Available to Work (Mark All Applicable Boxes):

Day      Evening     Night    Rotating
Full Time     Part Time     Other

Date Available to Work:

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)

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.

If you have been employed under a last name other than the one you are currently using, please state name.

 

Employment History

Please list your former employers starting with the most recent position

May we contact your present employer?
Yes     No
Company
Name
Supervisor's
Name
Address Phone
City

State

Zip

Date Started

Date Left

Type of Business

Full Time Part Time Per Visit

Salary

Reason For Leaving
OK to Contact Supervisor? Yes No

Describe your job title, responsibilities, and accomplishments:

Company
Name
Supervisor's
Name
Address Phone
City

State

Zip

Date Started

Date Left

Type of Business

Full Time Part Time Per Visit

Salary

Reason For Leaving
OK to Contact Supervisor? Yes No

Describe your job title, responsibilities, and accomplishments:

Company
Name
Supervisor's
Name
Address Phone
City

State

Zip

Date Started

Date Left

Type of Business

Full Time Part Time Per Visit

Salary

Reason For Leaving
OK to Contact Supervisor? Yes No

Described your job title, responsibilities, and accomplishments:

PERSONAL REFERENCES: (Name, Phone, Relationship)

 

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.

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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