MediNurse Application for Employment

MediNurse Application for Employment

Please carefully read and fill out the information below. If you have any questions or problems, contact us.

MediNurse is an equal opportunity employer.

This application will not be used for limiting or excluding any applicant from consideration for employment on any basis prohibited by local, state, or federal law. Applicants requiring reasonable accommodation in the application and/or interview process should notify a MediNurse representative.

Please fill out all sections and then click submit. All items in red are required - you must enter something in the blank, even if you do not know or are not sure of the information. You can always send us a message to explain or add more information.

*First Name:		*Last Name:

*Street:
*City:
*State:		*Zip Code:


*Phone Number:		2nd Phone:
*Email:
*Social Security Number:		Date of Birth:	ONLY if under age 18
*Position applying for:	RN LPN CNA Companion Other:
*Available to work:	Days Evenings Nights Any Rotating
	Full Time Part Time Temp work (such as summers, holidays)
*Date available to start:
*Proof of Citizenship:	If hired, would you be able to present evidence of your U.S. citizenship or proof of your legal right to work in the United States?		Yes No
Special Needs:	Are you in any way limited in your ability to safely perform the tasks of the position for which you are applying?		Yes No
	If yes, please explain:
Alternate Name:	Have you have been employed under a name other than the one you are currently using? Yes No If yes, what was the name used?
*EMPLOYMENT HISTORY	Please enter your three most recent employers, starting with your current position.

*Company		*Supervisor:
*Address		*Phone:
*City		*May we contact your supervisor? Yes No
*State		*Start Date:
*Zip Code:		*End Date:
*Type of Business		*Salary:
*Reason for leaving:
*Job Title:			Full Time Part Time Per Visit
*Job Description:

Company	Supervisor:
Address	Phone:
City	May we contact your supervisor? Yes No
State	Start Date:
Zip Code:	End Date:
Type of Business	Salary:
Reason for leaving:
Job Title:		Full Time Part Time Per Visit
Job Description:

Company	Supervisor:
Address	Phone:
City	May we contact your supervisor? Yes No
State	Start Date:
Zip Code:	End Date:
Type of Business	Salary:
Reason for leaving:
Job Title:		Full Time Part Time Per Visit
Job Description:

*EDUCATION
	School Name, Address	Degree, Certificate, number of years attended, or length of training	Description (list major, minor, topic, honors, achievements, etc.)
High School
College
College
College
Other Education, Training
Other Education, Training

PROFESSIONAL REFERENCES
	Name	Phone	Title/Company	Address
1
2
3

*PERSONAL REFERENCES
	Name	Phone	Relationship
1
2
3

**PLEASE READ CAREFULLY**

BY SUBMITTING THIS APPLICATION, YOU ARE AGREEING TO THE FOLLOWING:

I hereby affirm the information provided on this application is true and accurate to the best of my knowledge. I understand and agree that false, misleading or omitted information on this application or any subsequent documents used to secure my employment can be grounds for rejection of application or, if I am employed with MediNurse, may be considered justification for my immediate dismissal.

I understand that a routine inquiry may be made during MediNurse's initial or subsequent processing of my employment application into my character, general reputation, personal characteristics and mode of living. I also understand that upon written request, additional information as to the nature and scope of the inquiry, if one is made, will be provided.

RELEASE

I authorize all individuals, companies and institutions named in this application to provide MediNurse and any attorney, representative or agent thereof with any relevant information that may be required to arrive at an employment decision. I hereby release them from all liability for any damange whatsoever for issuing same.

How did you hear about us?		Newspaper Flyer Sign/Walk-in TV Referral Web Job Fair
	By clicking on submit below, I hereby affirm I understand and agree with the terms of this application for employment.


	Please press submit only once. You will see a results page momentarily. If you have any problems with this application, send an email message to webmaster@medinurse.com or call us. To cancel your application, click here to return to MediNurse.