Nursing Application
L & P Healthcare Staffing LLC
Position Applying For
Personal Information
Prefix
*
Mr.
Ms
Mrs.
Miss
Full Name
*
First Name
Middle Name
Last Name
Marital Status
*
Single
Married
Divorced
Widowed
Date Of Birth
*
-
Day
-
Month
Year
Date
Country Of Birth
*
Nationality
*
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Residential Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Tel. No.
Please enter a valid phone number.
Mobile Tel. No.
Please enter a valid phone number.
Email
*
example@example.com
Correspondence Address (If different from above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Educational Qualifications
Professional Qualifications
Name and Address of Employer and Nature of Business:
Dates To and From employed
Job Title: job Functions/Responsibilities
Final Salary and Reason for Leaving
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Skills (Nursing)
Skills (Others)
References
Name of references
Address Of References
Position Of Reference
Telephone/Fax No of Reference
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Had a chest X-ray in the past 12 months – If so state place / date / result
Yes
No
If yes please provide details
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Additional Information
Earliest Date Available If Appointed
Have you had any criminal convictions (including spent convictions under the rehabilitation of offenders Act 1974)?
Yes
No
Have you ever been employed by this company or its affiliates before?
Yes
No
Are you subject to any restrictions from previous employers which may restrict your working activities?
Yes
No
Have you applied for employment with this company before?
Yes
No
Do you have any physical impairment or health problem?
Yes
No
Have you been dismissed or suspended from the service of any employer?
Yes
No
Are you bound by any bond to serve the government, or any organization?
Yes
No
If yes to any of the above, please give details here
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Interview Questionnaire
Full Names
*
First Name
Last Name
Position Applied For
What are your strengths?
What are your weaknesses?
What are your goals?
What makes you a good candidate for this job?
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How would you promote infection control?
What would you do if you were uncertain of what to do on a shift?
What would you do if you did not understand or felt you didn't have enough training in certain areas of mandatory expectations?
You confirm that everything completed in this section is correct and attest to your character?
*
Yes, I agree
Date
*
-
Month
-
Day
Year
Date
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Terms Of Engagement
Contract For Services
Full Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: