New Hire Online Application
for LPN/LVN and RN
EagleWings Allied Health Staffing Agency
Personal Information
Applicant Name
*
First Name
Last Name
Applicant Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Applicant Email
*
example@example.com
Social Security Number
*
For Background Check and I-9 Verification purposes
Applicant Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Applicant Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What State are you Licensed, must be for this application
*
LPN/LVN or RN license no
State LPN/LVN or RN License no
*
Provide your license number of the state you are applying
Driving Licence no
*
For Background Check and I-9 Verification purposes
Do you own a Car
*
Yes
No
If yes, do you have an care insurance for the vehicle
*
Yes, have my car insurance
No, dont have a car insurance as it is expired
No, i do not own a car
Emergency Contact Information
*
Full Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Availability
*
Day interested to work f.e Mon and Tue Only
Start Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Shift Type
*
Per Diem
Contract
Both
Shift Preference
*
6:30am - 2:30pm
6:30am - 7:00pm
7:00am - 3:00pm
8:00am - 5:00pm
8:00am - 8:30pm
10:00am - 10:00pm
1:45pm - 10:15pm
2:30pm - 10:30pm
3:00pm - 11:00pm
6:30pm - 7:00am
11:00pm - 3:00pm
Education 1
Highest Degree and must be aligned to this position you are applying for
School Type
*
High School Equivalent / GED
Associate Degree
College or University
School Name
*
City & State
*
Degree
*
Major
Education 2
Nursing School Attended, if applicable
School Type
*
Nursing School
Others
N/A
Please Specify Other
School Name
*
if not applicable put N/A
City & State
*
if not applicable put N/A
Degree
*
if not applicable put N/A
Major
Employment
Employer Name
*
Title / Position
*
Current Employer?
*
Yes
No
Reason for Leaving
*
City
*
State
*
Employed from
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Employed to
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Supervisor / Contact
*
Ok to Contact?
*
Yes
No
Supervisor /Contact Email
*
example@example.com
Supervisor / Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Reference
Do not use family members, must be professional references
1. Professional Reference Full Name
*
Full Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Facility worked together
*
Date worked together From
*
Month/Year
Date worked together to
*
Month/Year
2. Professional Reference Full Name
*
Full Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Facility worked together
*
Date worked together From
*
Month/Year
Date worked together to
*
Month/Year
3. Professional Reference Full Name
*
Full Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Facility worked together
*
Date worked together From
*
Month/Year
Date worked together to
*
Month/Year
You understand that Facility has a 3 hours cancelation policy, if you call off a scheduled shift less than 2 hours to the start of your shift you will be fined. Facility will as us to withhold 2 hours of your next paycheck
*
I understand and agree
I consent and Authorized EagleWings Allied Staffing Agency LLC to run a Statewide Criminal Background Check, OIG, SAM, Education Verification and 10 panel Drug Test based on facility credential requirement on me
*
I agree
I hereby authorize EagleWings Allied Health Staffing Agency LLC to request and receive from all prior employers within one year of the date of application, any and all pertinent information concerning my prior employment and its termination, including the reasons for such termination.
*
I agree
You agree to receiving recurring automated text messages from Eaglewings Allied Health Staffing Agency to the phone number you provide. Msg&data may apply.
*
Opt-in to receive text message updates
Resume
*
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Updated with the Facilities you provided references
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of
CRP Card
*
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Only for LPN and RN, must be in person or Hybrid
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of
High School Diploma/GED
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Only for Facility located at Warsaw and Fulton in Ohio
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of
Clear Photo Showing your Face
*
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Required for your ID Card
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of
Physical/Health Assessment
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of
Covid Vaccine Card
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of
TB Test
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of
10 Panel Drug Test
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of
MMR Vaccine
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of
SSN Card
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Required for Background Check
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of
Driver License
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Required for Background Check
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of
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