REGISTERED NURSE SUPERVISOR APPLICATION FORM
APPLICANT INFORMATION
Name
*
FIRST NAME
MIDDLE NAME
LAST NAME
EMAIL
example@example.com
Phone Number
Please enter a valid phone number.
LICENSE RECEIVED?
YES
NO
LICENSE NUMBER
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
SOCIAL SECURITY NUMBER
BIRTHDAY
-
Month
-
Day
Year
Date
EXPERIENCE
PREVIOUS WORK EXPERIENCE #1
ORGANIZATION
CONTACT PERSON
TELEPHONE
DATES WORKED
/
Month
/
Day
Year
Date
MAY WE CONTACT?
YES
NO
PREVIOUS WORK EXPERIENCE #2
ORGANIZATION
CONTACT PERSON
TELEPHONE
DATES WORKED
/
Month
/
Day
Year
Date
MAY WE CONTACT?
YES
NO
PREVIOUS WORK EXPERIENCE #3
ORGANIZATION
CONTACT PERSON
TELEPHONE
DATES WORKED
/
Month
/
Day
Year
Date
MAY WE CONTACT?
YES
NO
PREVIOUS WORK EXPERIENCE #4
ORGANIZATION
CONTACT PERSON
TELEPHONE
DATES WORKED
/
Month
/
Day
Year
Date
MAY WE CONTACT?
YES
NO
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REFERENCES
REFERENCE #1
FULL NAME
POSITION/TITLE
TELEPHONE NUMBER
DATES KNOWN
/
Month
/
Day
Year
Date
REFERENCE #2
FULL NAME
POSITION/TITLE
TELEPHONE NUMBER
DATES KNOWN
/
Month
/
Day
Year
Date
REFERENCE #3
FULL NAME
POSITION/TITLE
TELEPHONE NUMBER
DATES KNOWN
/
Month
/
Day
Year
Date
CRIMINAL HISTORY
HAVE YOU EVERY BEEN CONVICTED OF ANY FELONY, MISDEMEANOR OR OFFENSES?
YES
NO
IF YES, PLEASE DESCRIBE THE DATE AND NATURE OF THE OFFENSE.
EDUCATION
COLLEGE #1
INSTITUTION NAME
LOCATION
MAJOR
GRADUATED?
YES
NO
END DATE
/
Month
/
Day
Year
Date
COLLEGE #2
INSTITUTION NAME
LOCATION
MAJOR
GRADUATED?
YES
NO
END DATE
/
Month
/
Day
Year
Date
COLLEGE #3
INSTITUTION NAME
LOCATION
MAJOR
GRADUATED?
YES
NO
END DATE
/
Month
/
Day
Year
Date
HIGH SCHOOL
NAME
LOCATION
GRADUATED?
YES
NO
END DATE
/
Month
/
Day
Year
Date
RN LICENSE
YES
NO
Expires
/
Month
/
Day
Year
Date
RN LICENSE NUMBER
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GENERAL AVAILABILITY
ARE YOU AVAILABLE FOR ALL HOURS?
YES
NO
BEING A LIVE-IN MEANS SEVERAL CONSECUTIVE DAYS OF CARE WHERE THE CAREGIVER STAYS AT THE CARE RECIPIENT'S HOME FOR THE ENTIRE NUMBER OF DAYS. ARE YOU INTERESTED IN PROVIDING LIVE-IN CARE?
YES
NO
IF YES, CHOOSE MINIMUM NUMBER OF DAYS
SKILLS & PREFERENCES
PLEASE CHECK ANY YOU ARE WILLING TO WORK WITH
please check IF YOU HAVE EXPERIENCE WITH
LIST ANY ADDITIONAL CERTIFICATIONS YOU HOLD
ADDITIONAL QUESTIONS
ARE YOU LEGALLY ELIGIBLE TO WORK IN THE USA?
YES
NO
ARE YOU AVAILABLE TO WORK ON CALL OUTS, IF NEEDED?
YES
NO
HAVE YOU EVER BEEN EMPLOYED AT OUR COMPANY?
YES
NO
DO YOU HAVE ANY FRIENDS OR FAMILY EMPLOYED AT THIS LOCATION?
YES
NO
DO YOU HAVE RELIABLE TRANSPORTATION
YES
NO
ARE YOU A SMOKER?
YES
NO
IF YES, HOW MANY PER DAY?
CPR CERTIFICATION
YES
NO
EXPIRATION DATE
/
Month
/
Day
Year
Date
TB SCREENING
YES
NO
LAST TEST TAKEN DATE
/
Month
/
Day
Year
Date
ANY PET ALLERGIES?
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1. Can you describe a time when you implemented a new program of study?
2. Have you experienced a time when you were unable to train clinical nursing staff in the use of a new piece of equipment?
3. What process do you follow after you learn that a staff member violated hospital policy?
4. What has been your most stressful experience? How did you cope with it?
5. Describe how you organize and prioritize your work.
6. If we hired you, tell me what would be your priorities for the first 6 weeks on the job?
EMERGENCY CONTACT
EMERGENCY CONTACT #1
NAME
RELATIONSHIP
PHONE
PHONE ALT
EMERGENCY CONTACT #2
NAME
RELATIONSHIP
PHONE
PHONE ALT
EMERGENCY CONTACT #3
NAME
RELATIONSHIP
PHONE
PHONE ALT
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Credentials
Driver's License
*
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Valid Car Insurance
*
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Resume
*
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Social Security
*
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Updated TB Screening Test
*
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Vaccine Card
*
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CPR/ BLS
*
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RN License
*
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RESTRICTIVE COVENANT
FULL NAME
SIGNATURE
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