* = Required Information
PERSONAL
Name* Soc. Sec. #
Present Address:
No Street City State Zip Code
Previous Address:
No Street City State Zip Code
Are you 18 years of age or over?
Yes No
Are you a U.S. citizen?
Yes Permanent Resident No
Do you have a valid operator's (driver's) license?
Yes No
If yes, license number and state State EXP. Date
EMERGENCY CONTACT
In case of an emergency notify: Name:
Address:
Relationship:
Phone
MILITARY SERVICE RECORD
Have you ever serviced in the Armed Forces?
Yes No
If yes, what branch?
Dates of duty: From: To:
List of Duties:
Present Membership in National Guard or Reserves:
Yes No
EMPLOYMENT DESIRED
Position:
RN LPN CNA MA
PT OT SP
Others, Please specify:
Date you can start:
Salary desired:
Type of Employment Desired:
Part-time (PRN) Full-time Temporary Day
Evenings Weekends
Were you previously employed by us?
Yes No
Education Name and Location of School NO. of years attended Did you Graduated? Course Or Major
Grammar School
Yes No
High School
Yes No
College
Yes No
Other Education
Yes No
EMPLOYMENT HISTORY
List your record of employment beginning with your present or most recent position.
Dates
From / To		 Name and Address of Employer Position Supervisor's Name and Title Reason for Leaving






Phone# Fax #
Describe the work you did:
Dates
From / To		 Name and Address of Employer Position Supervisor's Name and Title Reason for Leaving






Phone# Fax #
Describe the work you did:
Dates
From / To		 Name and Address of Employer Position Supervisor's Name and Title Reason for Leaving






Phone# Fax #
Describe the work you did:
Dates
From / To		 Name and Address of Employer Position Supervisor's Name and Title Reason for Leaving






Phone# Fax #
Describe the work you did:
May we contact the employers listed above?
Yes No
If not, indicates which one(s) you do not wish us to contact.
If hired and you are under 18 years of age, we will require, prior to starting work, an Age Certificate or Work Permit issued through the local school district.
THREE (3) REFERENCES:
CONDUCT OR ABUSE STATEMENT FORM
Never have been shown by credible evidence (e.g. a court or jury, a department investigation, or other reliable evidence) to have abused, neglected, sexually assaulted, exploited, or deprived any person or to have subjected any person to serious injury as a result of intentional or grossly negligent misconduct as evidenced by an oral or written statement to this effect obtained at the time of application;
I acknowledge that I have received and read the Misconduct or abuse statement form and that I understand its contents.
If applying online: Please be advised that
THIS AUTHORIZATION AND ATTESTATION PAGE WILL NEED YOUR HANDWRITTEN SIGNATURE AND DATE
I authorize Metnurse to contact each former employer, firm or corporation and the release of information concerning my credentials and job history. I authorize any of these persons to give all information concerning work-related items and I release all parties from liability for any damage that may result from furnishing same to you.
I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed; falsified statements on this application shall be grounds for dismissal.
I also understand that if accepted by the Metnurse, my employment is voluntarily entered into and I am free to resign at any time upon two weeks notice. Similarly, Metnurse is free to terminate my employment at any time. I further recognize that this application is not a contract and cannot create a contract.
I also understand that I am required to carry my own Professional Liability Insurance.
I also understand that my employment will continue to be either a Part-Time or PRN Position for 90 Days and on active schedule to be considered an employee of Metnurse Health Services, Inc. DBA (MHS). I also understand that I must give Two Week Notice prior to leaving any assigned case.
Applicant's Signature:
Date: