NSMC Employment Application

Employment Application

We are an equal-opportunity employer. All candidates who are extended an offer of employment will be required to undergo an FBI and Homeland Security background check and complete a drug screen.
Click the link below to download a printable job application.

DOWNLOAD APPLICATION
Position Applied for*
Applicant Information
Last*
First*
M. I.*
Date*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Email*
example@example.com
Date Available*

MonthDayYear
Date
Desired Salary $
Are you at least 18 years of age?*

YesNo
Have you ever applied to work here before*

YesNo
If yes, when?

MonthDayYear
Date
Have you ever worked here before?*

YesNo
If yes, when?

MonthDayYear
Date
Do you have a reliable means of transportation?*

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

YesNo
If yes, please explain.
Have you ever been convicted of. acrime or plead guilty to a felony?*

YesNo
If yes, please explain
Are you authorized to work lawfully in the United States?*

YesNo
Do you have any relatives that currently work at NSMC?*

YesNo
If yes, who?
Did anyone refer you to this position?*

YesNo
If yes, who?
License and Registration Information for Nurses and Professional Individuals
State
License Number
Expiration Date

MonthDayYear
Date
Type
State
License Number
Expiration Date

MonthDayYear
Date
Type
State
License Number
Expiration Date

MonthDayYear
Date
Type
State
License Number
Expiration Date

MonthDayYear
Date
Type
Shift Availability - Check all that you are willing to work*

DayEveningNightWeekendHolidayPRNPart-TimeFull-Time
Check all that apply for your experience / skills

Supervisor NurseRegistered NursePractical NurseCertified Nurse's AideNurses’ AideFood ServiceChef/CookHousekeepingLaundryLaboratory TechMedical Laboratory TechMaintenance MechanicEngineerPublic RelationsSecurity GuardEKG TechnicianRespiratoryRadiologyX-Ray TechnicianPhysical Therapy AideCOTAMedical TranscriptMedical Record ClerkMedical SecretarySwitchboardPharmacyPurchasingEEG TechnicianO.R. TechTypingDictationBookkeepingRecord FilingMailing ClerkBillingAccounts PayableOffice WorkCashierMicrosoft WordMicrosoft ExcelMicrosoft OutlookMicrosoft PowerPointAdobe PDFElectricianCarpenterPainter/PlastererPlumberHVACGeneral MaintenanceOther
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
Education
High School:*
From*
To:
Did you graduate?*

YesNo
Diploma
College
From
To
Did you graduate?

YesNo
Degree
Other
From
To
Did you graduate?

YesNo
Degree
Previous Employment
Company
Phone
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?

YesNo
Company
Phone
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?

YesNo
Company
Phone
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?

YesNo
References

Please list three professional references
Full Name*
Relationship*
Company*
Phone*
Address*
Full Name*
Relationship*
Company*
Phone*
Address*
Full Name*
Relationship*
Company*
Phone*
Address*
Disclaimer and Signature
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*

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Date*

MonthDayYear
Date
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Employment Application

Applicant Information

License and Registration Information for Nurses and Professional Individuals

Education

Previous Employment

References

Disclaimer and Signature