Florida Caring Nurses Registry Job Application

EMPLOYMENT APPLICATION

Florida Caring Nurses Registry is An Equal Opportunity Employer. Federal and state laws prohibit discrimination in employment practices because of race, color, religion, age, sex, national origin, or handicap. No question on this application is asked for the purpose of limiting or excluding any applicant’s consideration for employment (because of his or her race, color, religion, age, sex, national origin, or handicap).
Personal Information
Name*

First NameMiddle InitialLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
E-mail*

Confirmation Email
Phone*
Date of Birth*

MonthDayYear
Gender*

MaleFemale
Are you authorized to work in the U.S?*

YesNo
Are you above 18 years of age?*

YesNo
Languages spoken
Emergency contact*
List names and phone numbers of all emergency contacts
Education
Degree/Diploma
Enter your degree or diploma earned
License*
Select a valid license
Certificate

CPRRACSP
Certificate #
Enter certificate # if available

Work History
Current employer*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Supervisor's Name*
Position Held*
Start Date

MonthDayYear
End Date

MonthDayYear
Reason for Leaving*
May we contact this employer for a reference?*

YesNo
Employer 2*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Supervisor's Name*
Position Held*
Start Date

MonthDayYear
End Date

MonthDayYear
Reason for Leaving*
May we contact this employer for a reference?*

YesNo

References
Work Reference 1*
Name of Reference
Phone Number*

Area CodePhone Number
Email*
example@example.com
Work Reference 2*
Name of Reference
Phone Number*

Area CodePhone Number
Email*
Submit Application:
By clicking the submit button below, I authorize former employers, references and any other individual/organizations to provide information to Florida Caring Nurses Registry, LLC, and I hereby release and discharge any of the above and release Florida Caring Nurses Registry, LLC from any liability of any kind or nature. I also understand that it is my responsibility to keep such information current and accurate by updating it as often as necessary.

I agree to a criminal background check, fingerprint, physical examination if requested, and understand that failure to meet any medical and/or health requirements for the position may prevent my employment with Florida Caring Nurses Registry, LLC.

I further understand that, if hired, I may be required to provide proof that I am a citizen of the United States or currently authorized to work in the United States.

In consideration of my employment, I agree to conform to the hired company's rules and regulations, and I agree that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, by either me or the company's option.

"I certify that the statements made by me on this application are true and complete to the best of my knowledge and are made in good faith. I understand that if I knowingly make any misstatements of fact, I am subject to disqualification, dismissal, or other action pursuant to employment agency policy and procedure, and subject to criminal penalties as prescribed by law."
Signature
Print full name*
Date*

MonthDayYear
Date
Should be Empty:

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
6a-9a
9a-12p
12p-3p
3p-6p
6p-9p
9p-midnight
Overnight
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Personal Information

Education

Availability for work

Transportation

Abuse Investigation

Work History

References

Submit Application: