Welcome to the EmpowerBridge - Nursing & Healthcare Staffing - RN Employment Application. Thank you for your interest in joining our team. We value your privacy and assure that all information provided will be kept confidential and used solely for emp

Welcome to the EmpowerBridge - Nursing & Healthcare Staffing - RN Employment Application. Thank you for your interest in joining our team. We value your privacy and assure that all information provided will be kept confidential and used solely for employment purposes.

Please complete all sections accurately. Incomplete applications may delay the processing of your candidacy.
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Residential Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Position Applied For*
Preferred Assignment Type
Preferred Shifts

Day ShiftNight ShiftEvening ShiftWeekend Shift
Licensure Type*
License Number*
State of Licensure*
Certifications (Select all that apply)

Basic Life Support (BLS)Advanced Cardiac Life Support (ACLS)Pediatric Advanced Life Support (PALS)Other
Other Certifications (if any)
Primary Specialty*
e.g., ICU
Secondary Specialty*
e.g., ER
Years of Experience*
Previous Facilities Worked At (Optional)
Additional Skills or Certifications (Optional)
Earliest Start Date*

MonthDayYear
Date
Weekly Availability*

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Openness to Contract Extensions

YesNoMaybe
Most Recent Employer*
Previous Employer Details (Position, Duration, Responsibilities)
Second Most Recent Employer (if applicable)
Second Employer Details (Position, Duration, Responsibilities)
Reference 1 Name*
Reference 1 Title*
Reference 1 Organization*
Reference 1 Phone*
Please enter a valid phone number.
Reference 1 Email*
example@example.com
Reference 2 Name*
Reference 2 Title*
Reference 2 Organization*
Reference 2 Phone*
Please enter a valid phone number.
Reference 2 Email*
example@example.com
Work Authorization Status*

U.S. CitizenLegal Permanent ResidentWork Visa HolderOther
Explanation for Work Authorization (if applicable)
Felony Conviction (Select all that apply)*

No Felony ConvictionsYes, I have a felony conviction (please explain below)
Explanation of Felony Conviction (if applicable)
Medicare/Medicaid Exclusion List*

Not ExcludedExcluded
Vaccination Status (Select all that apply)

COVID-19 VaccinatedInfluenza VaccinatedHepatitis B VaccinatedOther Vaccinations
Additional Vaccination Details (if any)
Upload Resume*

Cancelof
Upload Nursing License*

Cancelof
Upload Certification Cards

Cancelof
Upload Photo ID*

Cancelof
Certification Paragraph (e.g., I certify that all information provided is true and complete)*
E-Signature (Type Your Name as Signature)*

First NameLast Name
Date of Signature*

MonthDayYear
Date
Should be Empty:

Welcome to the EmpowerBridge - Nursing & Healthcare Staffing - RN Employment Application. Thank you for your interest in joining our team. We value your privacy and assure that all information provided will be kept confidential and used solely for employment purposes.