WGTC Practical Nursing Online Employment Application

Online Employment or Training Application

Please complete the form below to apply for a position with us or to request Training Hours
Applicant Information
Full Name*

First NameMiddle NameLast Name
Date of Birth*

DayMonthYear
Current Address*

Street Address

Street Address Line 2

CityCounty

PostcodeCountry
Email Address*
Phone Number*
Applying for Position*
Desired start date

DayMonthYear
Have you ever worked for this company?
If yes, when?
Are a citizen of the US?*
If no, are you authorized to work in the US?
Have you ever been convicted of a crime?
If yes, explain:
Do you have a current nursing license?
If yes, what state?
Has your nursing license ever been suspended or revoked?
Have you ever been disciplined for unprofessional or unethical nursing to include abuse or neglect?
If so, explain:
List availability hours or Days of the week.

Additional Skills/Qualifications
List additional skills and qualifications (e.g CPR, foreign language, other education/training):
Disclaimer and Signature
I understand that my employment with the company shall be probationary for a period of ninety (90) days, and further that at any time during the probationary period or thereafter, my employment relationship is terminable at will for any reason by either party.

I certify that my answers are true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
Signature

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Online Employment or Training Application