NSMC Employment Application

Click the link below to download a printable job application.

DOWNLOAD APPLICATION

Position Applied for

Last

First

M. I.

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone

Format: (000) 000-0000.

Email

example@example.com

Date Available

Date

Desired Salary $

Are you at least 18 years of age?

Have you ever applied to work here before

If yes, when?

Date

Have you ever worked here before?

If yes, when?

Date

Do you have a reliable means of transportation?

Do you have other obligations that might cause you to miss work?

If yes, please explain.

Have you ever been convicted of. acrime or plead guilty to a felony?

If yes, please explain

Are you authorized to work lawfully in the United States?

Do you have any relatives that currently work at NSMC?

If yes, who?

Did anyone refer you to this position?

If yes, who?

State

License Number

Expiration Date

Date

Type

State

License Number

Expiration Date

Date

Type

State

License Number

Expiration Date

Date

Type

State

License Number

Expiration Date

Date

Type

Shift Availability - Check all that you are willing to work

Check all that apply for your experience / skills

Supervisor Nurse Years of Experience

Registered Nurse Years of Experience

Practical Nurse Years of Experience

Certified Nurse's Aid Years of Experience

Nurses' Aid Years of Experience

Food Service Years of Experience

Chef/Cook Years of Experience

Housekeeping Years of Experience

Laundry Years of Experience

Laboratory Tech Years of Experience

Medical Laboratory Tech Years of Experience

Maintenance Mechanic Years of Experience

Engineer Years of Experience

Public Relations Years of Experience

Security Guard Years of Experience

EKG Technician Years of Experience

Respiratory Years of Experience

Radiology Years of Experience

X-Ray Technician Years of Experience

Physical Therapy Aid Years of Experience

COTA Years of Experience

Medical Transcript Years of Experience

Medical Record Clerk Years of Experience

Medical Secretary Years of Experience

Switchboard Years of Experience

Pharmacy Years of Experience

Purchasing Years of Experience

EEG Technician Years of Experience

O.R. Tech Years of Experience

Typing Years of Experience

Dictation Years of Experience

Bookkeeping Years of Experience

Record Filing Years of Experience

Mailing Clerk Years of Experience

Billing Years of Experience

Accounts Payable Years of Experience

Office Work Years of Experience

Cashier Years of Experience

Microsoft Word Years of Experience

Microsoft Excel Years of Experience

Microsoft Outlook Years of Experience

Microsoft PowerPoint Years of Experience

Adobe PDF Years of Experience

Electrician Years of Experience

Carpenter Years of Experience

Painter/Plasterer Years of Experience

Plumber Years of Experience

HVAC Years of Experience

General Maintenance Years of Experience

Other Years of Experience

High School:

From

To:

Did you graduate?

Diploma

College

From

To

Did you graduate?

Degree

Other

From

To

Did you graduate?

Degree

Company

Phone

Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Address

Supervisor

Job Title

Starting Salary $

Ending Salary:$

Responsibilities

From

To

Reason for Leaving

May we contact your previous supervisor for a reference?

Company

Phone

Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Address

Supervisor

Job Title

Starting Salary:$

Ending Salary:$

Responsibilities

From

To

Reason for Leaving

May we contact your previous supervisor for a reference?

Company

Phone

Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Address

Supervisor

Job Title

Starting Salary $

Ending Salary $

Responsibilities

From

To

Reason for Leaving

May we contact your previous supervisor for a reference?

Full Name

Relationship

Company

Phone

Format: (000) 000-0000.

Address

Full Name

Relationship

Company

Phone

Format: (000) 000-0000.

Address

Full Name

Relationship

Company

Phone

Format: (000) 000-0000.

Address

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, / understand that false or misleading information in my application or interview may result in my release.

Signature

Upload Resume

Date

Employment Application

Applicant Information

License and Registration Information for Nurses and Professional Individuals

Education

Previous Employment

References

Disclaimer and Signature