• Candidate Application Form

  • Contact Information

  • Format: (000) 000-0000.
  • Date of Birth*
     - -
  • If hired, will you be able to provide acceptable documentation to complete Form I 9 (employment eligibility verification)?*
  • Are you authorized to work in the United States?*
  • Position and Availability
  • What shifts are you willing to work?*
  • Application Details
  • Are you willing to travel to different facilities within a 30 to 60 minute radius?*
  • Do you have reliable transportation?*
  • Professional Licensure and Certifications
  • Do you hold licenses in any additional states?*
  • Are you currently in good standing with all boards or registries where you are licensed or certified?*
  • Current certifications*

  • Gaps, Disciplinary History, and Background

  • Do you have any gaps in employment longer than 3 months in the last 5 years?*
  • Have you ever been terminated, asked to resign, or not eligible for rehire at any job?*
  • Have you ever had a professional license or certification suspended, revoked, or restricted in any way?*
  • Have you ever been excluded from participation in Medicare, Medicaid, or any federally funded healthcare program?*
  • Have you ever been convicted of, pled guilty to, or pled no contest to a crime other than minor traffic violations?*
  • Are you currently under investigation by any licensing board, employer, or regulatory body?*
  • Are you willing to complete a background check and drug screen if required by CNE Medical Staffing or client facilities?*
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