Empowered Nurses' Application

Empowered Nurses' Independent Contractor Application and/or Employee Application and/or Vendor Application

Please complete the form below.
Full Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
example@example.com
Phone Number
LinkedIn
Contractor/Employee Position Applied for:
How did you hear about us
Available Start Date

MonthDayYear
Date
Upload Your Resume*

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Cover Letter/Optional

TB Test/If you do not have, you can obtain this through one of our Client Facilities.

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Covid Vaccination Card/Not required for all positions

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CPR Card

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Contractor Liability Insurance Proof $1,000,000/claim and $6,000,000 aggregate

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ID Badge Pic:, Must be forward facing, no masks/glasses/hat, great lighting, professional looking and appropriate for work*

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I9 Verification; Examples: Driver's License, Passport, Birth Certificate, SS Card, etc.*

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I9 Verification; Examples: SS Card if using Driver's License for 1st verification above. PLEASE GOOGLE I9 VERIFICATION FOR FUTHER DETAILS.

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I declare that this application has been completed to the best of my knowledge and understand that false information may lead to disqualification or revocation of my application with Empowered Nurses LLC*

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APPLICANT RELEASE AGREEMENT AND DISCLOSURE TO EMPLOYMENT/Independent Contractor Background Check In connection with any application made by me, I understand Empowered Nurses may be requesting information from various Federal, State, and other agencies which maintain records concerning past activities relating to my credit, criminal, driving, health, civil, and other records and experiences, including claims involving me in the files of insurance companies, if any. These reports may also include information on education, experience, work habits, and performance, along with reasons for termination of employment from previous employers, if any. I hereby authorize Empowered Nurses to obtain background information as well as verification of professional licenses/certifications and education for consideration of employment. The verification will be limited to verifications of professional license/certification and education. In addition, I hereby authorize Empowered Nurses, or any of its agents, to obtain any information required and requested in reference to my current and previous employment. I hereby release all such employers from any and all liabilities for any damage whatsoever for supplying Empowered Nurses with the same information. Without reservation, I authorize any party or agency contacted to furnish the above-mentioned information a release all parties involved from any liability and/or responsibility for doing so. I hereby consent to any potential employer obtaining such information from Empowered Nurses and/or any of its agents. This authorization and consent shall be submitted in an original, electronic, or copy form. Lastly, any Clients requiring any of this information as I work within their facilities/outside of their facilities, both cases as a Client of Empowered Nurses, I understand that this information will be provided to that facility as it pertains to State and Federal requirements in order for me to be staffed in that particular instance. Then and only then will my information be shared. In the event my information is shared with a Client of Empowered Nurses, and my shift or contract or work is cancelled, postponed, skipped, called-off, the Client of Empowered Nurses will be required to completely delete, destroy, shred, or place in locked box with proper information protective company for safe destruction, in order to not share or expose your confidential information outside of proper agents to utilize strictly for employment purposes. FOR INFORMATION ABOUT YOUR RIGHTS, go to www.ftc.gov/credit or write to: Consumer Response Center, Room 130-A, Federal Trade Commission, 600 Pennsylvania Ave. N.W., Washington, D.C 20580. By my signature I confirm I understand and agree with the above. Printed Full Name(Middle name included):__________________________________________________ Signature:_________________________________________________________ Full Social Security Number:____________________________________ Date of Birth:_____________________________________________ *EEOC notice N-915.043 II states “a pre-employment inquiry on the part of the employer for information such as date of birth or state age on an application form is not, in itself a violation of the age discrimination ace (ADEA)”. The ADEA of 1967 prohibits discrimination in employment based on age.*

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DRUG TESTING AGREEMENT Employees and Independent Contractors (As required by Client Facilities/Law/State or Federal Regulation) I understand as a requirement for employment/or contracting as an Independent Contractor with EMPOWERED NURSES, I may be requested to submit a urine drug/alcohol test that will be processed at a designated laboratory, which will provide the results of the test to EMPOWERED NURSES. I also understand that a positive drug screen will be reviewed by a Medical Review Officer (MRO) in relationship to the lab and may result in the denial/termination of my employment with EMPOWERED NURSES. I understand that a drug/alcohol test may be requested at any point during employment, without cause or justification, with knowledge that in the event I test positive on drug screen, after review by a Medical Review Officer (MRO) in relationship to the lab, may result in denial/termination of my employment with EMPOWERED NURSES. I understand that a drug/alcohol test will be required with all Workman’s Compensation related claims, injuries, death, or at any point an agent of Empowered Nurses and/or it’s Client you are working through requests, you must comply, otherwise, refusal may result in termination by your own determination, as applicable by governing laws. I hereby consent and give authorization to any EMPOWERED NURSES’ designated laboratory to provide the results of the urine drug/alcohol test to Empowered Nurses. I also consent and give authorization to EMPOWERED NURSES to provide the results of the urine drug/alcohol test to any facilities that I may be placed while employed with EMPOWERED NURSES. By signing this document, I indicate I have read, understand, and agree to EMPOWERED NURSES drug and alcohol testing policy. I also understand a negative drug/alcohol test is potentially required for initial and/or continued employment with EMPOWERED NURSES. My signature constitutes my consent for drug and/or alcohol testing by an EMPOWERED NURSES designated laboratory. It also constitutes consent for the designated laboratory to release the result of the drug/alcohol test to EMPOWERED NURSES. Independent Contractors: This is permission to set you up with drug screen in the event it is required for Contract Labor. This is not mandatory, but allowing us to set this up on your behalf. You are fully able and authorized to obtain your own drug screens as required through Client’s we connect you to and to utilize as required in contractual agreements between Empowered Nurses LLC and CLIENT and “YOU” the CONTRACTOR. By my signature, I confirm I understand and agree to the above.*

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Social Security Number:*
Three Professional References: Name/Number/Email*
Are you legally eligible to work in the United States?*

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Empowered Nurses' Independent Contractor Application and/or Employee Application and/or Vendor Application