Employment In addition to the Employment Application, NursePartners also requires a pre-employment health screening. Click here to download our Health Screen Form. Employment Application NursePartners does not discriminate in hiring or employment on the basis of ancestry, race, color, religion, national origin, sex, sexual orientation, age, military status, veteran status, or disability. No question on the application is intended to secure information to be used for such discrimination. This application will be given every consideration; however, its receipt does not imply employment for the applicant. Personal InformationName* First Last Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Home PhoneCell PhoneCell Phone CarrierJob Interests LPN RN Certified Nursing Assistant Care Companion Administrative Assistant Business Office Manager Customer Service Manager Staffing Manager Other If "Other"Check the area(s) that best match your interests. Nursing Home Sub-Acute Facility Transitional Care Unit Capacity Staff Nurse Unit Supervisor Shift Supervisor Check the shift(s) and you are available to work Full Time Part Time Weekdays Weekends 7am - 3pm 3pm - 11pm 11pm - 7am 7pm -7am Check the days you are available to work Monday Tuesday Wednesday Thursday Friday Saturday Sunday EducationHigh School NameDiploma/DegreeCollege NameDiploma/DegreeCollege NameDiploma/DegreeTrade/Other ProfDiploma/DegreeLicense/CertificationLicense TypeExpiration DateLicense/Cert No.StateLicense TypesExpiration DateLicense/Cert No.StateCPR Expiration DateLast Physical ExamLast TB/CXR DateWork ExperienceMost Recent or Current EmployerSupervisor's Name/TitleYour PositionStart DateEnd DateStreet AddressRate of PayTelephoneMay we contact?Reason for leavingPrevious EmployerSupervisor's Name/TitleYour PositionStart DateEnd DateStreet AddressRate of PayTelephoneMay we contact?Reason for leavingPrevious EmployerSupervisor's Name/TitleYour PositionStart DateEnd DateStreet AddressRate of PayTelephoneMay we contact?Reason for leavingPrevious EmployerSupervisor's Name/TitleYour PositionStart DateEnd DateStreet AddressRate of PayTelephoneMay we contact?Reason for leavingProfessional ReferencesPlease provide 3 professional (RN or LPN) referenceName & TitleCompanyPhoneName & TitleCompanyPhoneName & TitleCompanyPhoneEmergency ContactName PhoneOther InformationInformation provided in response to these questions will not necessarily bar employment. Answers to questions 1, 3 or 5 if “yes,” please give full details in the box provided.1. Has your clinical license to practice in any jurisdiction ever been limited, suspended or revoked?YesNoIf "Yes" please provide details2. Do you have the ability to perform all essential job functions?YesNo3. Have you been convicted of a felony within the past five years?YesNoIf "Yes" please state the offense and findings4. Have you ever applied for a position or been employed before with NursePartners?YesNo5. Have you ever missed work for more than five days?YesNoIf "Yes" please explainAgreementI certify that the statements made on this application are true and correct to the best of my knowledge and belief and hereby grant NursePartners permission to verify such answers. I understand that any false statement on this application will be considered as sufficient cause for rejection of this application or for dismissal if such false statement is discovered subsequent to my employment. I authorize written access to any records concerning my education or employment background. I understand that, if any inquiry is made, all information as to its nature and scope will be supplied upon request. Additionally, I authorize present and former employers, and individuals I have listed as personal references, to furnish information about my employment record, including a statement of the reason for the termination of my employment, work performance abilities, and other qualities pertinent to my qualifications for employment, hereby releasing them from any and all liability for damages arising from furnishing the requested information. I will have to pass a post employment health screen as a condition of employment. If this application is considered favorably, I agree to abide by and comply with all the employer’s rules. By checking "I Agree", I acknowledge and agree to the preceding statement:* I Agree Please check:PhoneThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.