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Careers
1
NAME/ADDRESS
2
DESIRED EMPLOYMENT
3
EDUCATION
4
EMPLOYMENT HISTORY
5
PERSONAL REFERENCES
6
PHYSICAL RECORD
7
LICENSES/CERTIFICATION
8
ADDITIONAL AREAS OF EXPERTISE
9
EMERGENCY CONTACT INFORMATION
10
NURSE REGISTRY AUTHORIZED REPRESENTATIVE INTERVIEWER
Date
(Required)
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Name
(Required)
FIRST NAME
MIDDLE NAME
LAST NAME
Address
(Required)
Street Address
City
State / Province / Region
ZIP / Postal Code
Enter Country Here
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Phone
(Required)
Email
(Required)
Home Number
(Required)
SOCIAL SECURITY NUMBER
(Required)
DATE OF BIRTH
(Required)
MM slash DD slash YYYY
DRIVER'S LICENSE NUMBER
(Required)
POSITION
(Required)
DATE YOU CAN START
(Required)
MM slash DD slash YYYY
ARE YOU CURRENTLY EMPLOYED?
(Required)
Yes
No
MAY WE INQUIRE OF YOUR CURRENT EMPLOYER?
(Required)
Yes
No
HAVE YOU APPLIED TO THIS NURSE REGISTRY BEFORE?
(Required)
Yes
No
When?
MM slash DD slash YYYY
HIGH SCHOOL NAME AND LOCATION OF SCHOOL
(Required)
YEARS ATTENDED
(Required)
DATE GRADUATED
(Required)
MM slash DD slash YYYY
Degree
(Required)
UNIVERSITY/COLLEGE UNDERGRADUATE NAME AND LOCATION OF SCHOOL
(Required)
YEARS ATTENDED
(Required)
DATE GRADUATED
(Required)
MM slash DD slash YYYY
Degree
(Required)
UNIVERSITY/COLLEGE GRADUATE NAME AND LOCATION OF SCHOOL
(Required)
YEARS ATTENDED
(Required)
DATE GRADUATED
(Required)
MM slash DD slash YYYY
Degree
(Required)
TRADE, BUSINESS OR CORRESPONDENCE NAME AND LOCATION OF SCHOOL
(Required)
YEARS ATTENDED
(Required)
DATE GRADUATED
(Required)
MM slash DD slash YYYY
Degree
(Required)
EMPLOYER
JOB TITLE
Address
DUTIES
Phone Number
Salary
DATE FROM
MM slash DD slash YYYY
DATE TO
MM slash DD slash YYYY
REASON FOR LEAVING
EMPLOYER
JOB TITLE
Address
DUTIES
Phone Number
Salary
DATE FROM
MM slash DD slash YYYY
DATE TO
MM slash DD slash YYYY
REASON FOR LEAVING
EMPLOYER
JOB TITLE
Address
DUTIES
Phone Number
Salary
DATE FROM
MM slash DD slash YYYY
DATE TO
MM slash DD slash YYYY
REASON FOR LEAVING
NAME
OCCUPATION
ADDRESS
RELATIONSHIP
PHONE NUMBER
YEARS KNOWN
NAME
OCCUPATION
ADDRESS
RELATIONSHIP
PHONE NUMBER
YEARS KNOWN
NAME
OCCUPATION
ADDRESS
RELATIONSHIP
PHONE NUMBER
YEARS KNOWN
DO YOU HAVE ANY PHYSICAL DISABILITIES THAT WOULD PREVENT YOU FROM PERFORMING WORK FOR WHICH YOU ARE APPLYING?
Yes
No
PLEASE DESCRIBE
HAVE YOU EVER BEEN INJURED?
Yes
No
PLEASE DESCRIBE
TYPE
LICENSE / CERTIFICATION NUMBER
EXPIRATION DATE
MM slash DD slash YYYY
STATE ISSUED
TYPE
LICENSE / CERTIFICATION NUMBER
EXPIRATION DATE
MM slash DD slash YYYY
STATE ISSUED
TYPE
LICENSE / CERTIFICATION NUMBER
EXPIRATION DATE
MM slash DD slash YYYY
STATE ISSUED
AREAS OF SPECIALIZED STUDY, RESEARCH OR ADDITIONAL EXPERIENCE
LIST THE FOREIGN LANGUAGES YOU SPEAK FLUENTLY
U.S. MILITARY SERVICE
SEPARATION RANK
PRESENT MEMBERSHIP IN NATIONAL GUARD OR RESERVES
Yes
No
NAME
RELATION
ADDRESS
Phone
NAME
RELATION
ADDRESS
Phone
checkbox
I voluntarily give Firstnet Nurse Registry the right to make a thorough investigation of my past employment. I agree to cooperate in such an investigation. I understand that my employment will be based in part on the accuracy of the information provided on this application
If I am employed Firstnet Nurse Registry. I agree to abide by the rules and regulations of the company. I fully understand that all records pertaining to my employment are to remain the property of the company, and that hours of work and other working conditions are subject to change at the organization's discretion.
I certify that I fully understand all requests for information contained in this application, and I certify that the information supplied by me, on this form and elsewhere in conjunction with obtaining employment, is complete and correct to the best of my knowledge and hereby grant the company permission to verify such information and investigate all references including a criminal history check with local, state and federal agencies as well as a level-2 background check. I understand that any false or misleading statements, omission or misrepresentation on this application will be considered sufficient cause for rejection of this application or for dismissal, if such information or omission is discovered subsequent to my employment.
I authorize the employers, schools, or persons named above to give any information regarding my previous employment, character, general reputation, and other personal characteristics, together with any information regarding me. I hereby release the company, employers, schools or person from all liability for any damage resulting from issuing the information. I further certify that I have not entered into any agreement with any previous employer or other organization that would prevent or restrict my employment with the company at this time or in the future.
DO YOU HAVE A DRIVER'S LICENSE?
Yes
No
DO YOU OWN A CAR?
Yes
No
WHAT SHIFTS WOULD YOU PREFER?
Days
Nights
PM
Live-In
HOW DID YOU HEAR ABOUT US?
ATTACH RESUME
Max. file size: 512 MB.
Signature
Date
MM slash DD slash YYYY
HIRED
Yes
No
Name
Date
MM slash DD slash YYYY
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