Job Application: Registered Nurse for Washington & Canonsburg Area

Applying for: Registered Nurse for Washington & Canonsburg Area

Fields marked with an asterisk (*) must be filled out before submitting.

Personal Information

First Name *
Last Name *
Middle Initial
Social Security Number *
Current Address *
Years at this Address *
Primary Phone Number *
Email Address *
Date of Birth *

Position Information

Desired Salary
Days Available to Work	No Preference All Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Hours Available to Work	Any AM PM
How many hours can you work weekly?
Can you work nights?
Employment Desired *
Date available to work? *
Have you ever worked for The Caring Mission Home Care Services before?
Were you referred to us by one of your caregivers? (Provide Name)

Education

Type of School *
Name and Address of School *
Years Completed *
Major/Degree *
Have you ever been convicted of a crime? *
If yes, please explain the nature of the conviction or offense, how recently they occurred and any type of rehabilitation

Military

Have you ever been in the Armed Forces *
Are you now a member of the National Guard? *
Specialty
Date Entered
Discharge Date

Transportation

What is your means of transportation to work? *
Do you have a valid driver’s license? *
Driver license number
State of issue
Expiration date
Do you have current auto insurance?
Policy expiration date
Have you had any accidents during the past three years? *
If Yes, how many?
Have you had any moving violations during the past three years? *
If Yes, how many?

Work Experience

Name of employer *
Address *
Phone Number *
Name of last supervisor *
Employment Start Date *
Employment End Date *
Starting and Ending Salary
Your last job title *
Reason for leaving (be specific) *
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company *
May we contact this employer? *

Name of employer
Address
Phone Number
Name of last supervisor
Employment Start Date
Employment End Date
Starting and Ending Salary
Your last job title
Reason for leaving (be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company
May we contact this employer?

Name of employer
Address
Phone number
Name of last supervisor
Employment Start Date
Employment End Date
Starting and Ending Salary
Your last job title
Reason for leaving (be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company
May we contact this employer?

May we contact your present employer?
Did you complete this application yourself?

I hereby authorize you to release all information regarding my employment and attendance record. By clicking this release, I release The Caring Mission Home Care Services from any and all liability associated with releasing such information.
Authorization Release *	I Agree

References

Please list two references other than relatives or past employers.
Name *
Position *
Company and Address *
Telephone *

Name *
Position *
Company and Address *
Telephone *

If you have a Resume, please upload it here.
If you have a Cover Letter, please upload it here.

Disclosure

The Fair Credit Reporting Act, as amended by the Consumer Credit Reporting Reform Act of 1996, requires that we advise you that for purposes of employment, promotion, reassignment or continued employment with The Caring Mission Home Care Services, a consumer report and/or investigative consumer report (i.e. background check) may be obtained by The Company, which may include information on your education, former employers, motor vehicle and felony and related misdemeanor records. It may also include information related to your creditworthiness, credit standing, credit capacity, general reputation or mode of living. If you are and not employed as the result of a consumer report and/or investigative consumer report, the Company will notify you in writing and provide you with a copy of the report, the name, address and telephone number of the provider of this report, and a description of your rights as a consumer as prescribed by the Federal Trade Commission under Section 609(c)(3). [§ 1681g].

Authorization

During the application process, and at any time during your employment, you hereby authorize the Company to procure a consumer report and/or investigative consumer report, which may require the release of information from my personnel record/file to the consumer reporting agency preparing the consumer report and/or investigative consumer report. By signing below, you confirm that you have been advised of, understand and will be subject to the above-stated policy.

Full Name *
Today's Date *