PrimeNurse Healthcare Solutions

Personal Information

Full Name *

Address *

Phone Number *

Email Address *

Date of Birth *

Social Security Number

Position Applied For

Registered Nurse (RN)

Licensed Practical Nurse (LPN)

Certified Nursing Assistant (CNA)

Other

Availability

Full-Time

Part-Time

Per Diem

Shift Preferences:

Day

Night

Weekends

Form of Verification to Confirm Identity

Driver’s License

State ID

Passport

Other:

Education

Nursing School

Name:

Location:

Degree Obtained:

Graduation Year:

High School

Name:

Location:

Graduation Year:

Additional Certifications or Training:

Licensure

Type of License: *

RN

LPN

CNA

Other:

License Number: *

Issuing State: *

Expiration Date: *

Work Experience

Professional References

Skills and Qualifications

Special Skills:

Languages Spoken:

Computer Skills:

Other Relevant Skills:

Additional Skills:

CPR Training

Date of CPR Training: *

Expiration Date: *

Certification Agency: *

Mantoux Test

Date of Test: *

Result: *

Positive

Negative

Administered By: *

Background Information

Have you ever been convicted of a felony? *

Yes

No

Emergency Contact Information

Name:

Relationship:

Phone Number:

Address:

Applicant’s Statement

I certify that the information provided is accurate to the best of my knowledge. I authorize the verification of this information. By submitting this form, I acknowledge that I have read, understood, and agree to the terms and conditions of the , including the policies regarding the collection and use of my data.

Signature:

Application Form

Personal Information

Position Applied For

Availability

Shift Preferences:

Form of Verification to Confirm Identity

Education

Nursing School

High School

Licensure

Work Experience

Professional References

Skills and Qualifications

CPR Training

Mantoux Test

Background Information

Emergency Contact Information

Applicant’s Statement