Nursing Services of Palm Beach: Application

Background Information
Full Name:*

First NameMiddle NameLast Name
Current Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Date of Birth:*
E-mail Address:*
Cell Phone:*
Home Phone:*
Cell Carrier:*
Position Applying For:*
Wages Desired:*
Date Available for Work:*
Have You Previously Been Employed By NSPB?:*

YesNo
Date(s):
Start Date - End Date
Position Held:
In Case of Emergency, Notify:*

0/260
Emergency Contact:*
Education and Training
Degrees of Education Completed:

High SchoolCollegeOther Education
Name of School:*
Diploma/Degree/Certification/License:*
List any other education, training, special skills, or certificates/licenses that you possess which are relevant to the position for which you have applied:

0/1000
List any machines or equipment that you are qualified and experienced at operating that are relevant to the position for which you have applied:

0/1000
Qualifications/Experience and Skills

Please check all areas of experience that apply. DO NOT include school experience.
Only Select Areas with Experience in the Last 3 Years:

Alcohol DetoxBurnsCardiac CareChild CareDoctor's OfficeHome CareIntensive CareLabor & DeliveryMedical FloorMedicare Home CareMedicationsNeurologicalNurseryNursing HomeOncologyOperating RoomOrthopedicsOB/GYNPediatricsPrivate Duty in FacilityPsychiatricRehabilitation CareSurgical FloorUrologyStaffing in Facility

Skills:*

	Yes	No
Alzheimer's Care
Assistance w/ Self Medication Administration
Bed/Bath
Blood Pressure
Cardiac Care
Catheter Care/Foley
Child Care
Colostomy
Dementia Care
Diabetic Care
Enema
Hoyer Lift
Ice Bags
Intake & Output
IV Certified
Light Housekeeping
Meal Preparation/Cooking
Medication Administration
Oxygen
Psychiatric Patients
Range of Motion
Specimen Collection
Substance Abuse
Traction
Transfers/Ambulation
Tube Feeding
Vital Signs
Wound Care

Work Experience
List Current and/or Former Employers, Beginning with Most Recent:
Company Name:
Type of Business:
Address:
Phone:
Employment Period:
Start Date - End Date
Employed:

Full-TimePart-Time
Wages:

Starting

Last
Supervisor:
Name and Title
May We Contact?:

YesNo
State Last Job Title and Describe Your Work:

0/1000
Reason for Leaving (If Applicable):

0/500
Company Name:
Type of Business:
Address:
Phone:
Employment Period:
Start Date - End Date
Employed:

Full-TimePart-Time
Wages:

Starting

Last
Supervisor:
Name and Title
May We Contact?:

YesNo
State Last Job Title and Describe Your Work:

0/1000
Reason for Leaving:

0/500
Company Name:
Type of Business:
Address:
Phone:
Employment Period:
Start Date - End Date
Employed:

Full-TimePart-Time
Wages:

Starting

Last
Supervisor:
May We Contact?:

YesNo
State Last Job Title and Describe Your Work:

0/1000
Reason for Leaving:

0/500
Personal Information
Have you ever worked as a Caregiver?:*

YesNo
How Long?:
Are you working for another Agency?:*

YesNo
Name:
Address:
Phone:
Fax:
May We Contact?:

YesNo
Current Employer/Patient (Not Agency):
Name
Address
How long have you been working there?:
What hours do you work?:
Do you have any physical limitations?:*

YesNo
Please Explain:

0/750
Do you have any relatives or friends signed up with us?:*

YesNo
Please Provide the Name:
Have you ever been convicted of a crime, felony, or misdemeanor offense?:*

YesNo
Please Explain;

0/750
How many days can you work?:*
What hours are you available to work?:*
Work wanted per week:*
Would you accept a LIVE IN job?:*

YesNo
How many days can you LIVE IN?:
Can you work weekends?:

DaysNights
Can you LIVE IN weekends?:*

YesNo
ARE YOU AVAILABLE FOR EMERGENCY COVERAGE?:*

YesNo
Do you have a fear of animals?:*
References
Please verify that you are human*
Should be Empty:


Starting
Last


Starting
Last


Starting
Last

Background Information

Education and Training

Qualifications/Experience and Skills

Work Experience

Personal Information

References