Early interest form
Thank you for your interest in participating in JCS Health Connect coming July 17. Please complete this quick form so we can confirm your availability and role.
Full name
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Phone number
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Home address
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Date of birth
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Month
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Day
Year
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Nursing License type:
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RN
LPN/LVN
CNA
Other
Are you a certified Nursing Assistant ?
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yes
no
in training
State licensed In
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Certification (select all that apply)
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BLS
ACLS
PALS
TNCC
NIHSS
Other
Years of nursing experience
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Please Select
less than 1 year
1-3 years
4-6 years
7+ years
Primary specialty
*
Please Select
behavioral health
correctional
Med-Surg
Home Health
Preferred work type
*
Please Select
per diem
permanent placement
Other specialties or skills
Where are you located ?
Are you open to travel assignments (future expansion)
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yes
no
Preferred shifts
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Day
Night
variable
Other
Do you currently have updated credentials?
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Yes, all updated
Partially updated
Not updated yet
Other
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I certify that all information provided is true and accurate. I understand falsification may result in disqualification. I consent to background checks, license verification, and drug screening as required by the agency and faculties.
Please provide day of application completion
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Month
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Day
Year
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Submit
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