HEALTHCARE APPLICATION

DATE:
   POSITION YOU ARE APPLYING FOR:
NAME:
   ADDRESS:
   CITY, STATE, ZIP:
OTHER NAMES YOU HAVE USED WHILE EMPLOYED:
   HOME PHONE:
   WORK PHONE:
EMAIL ADDRESS:
  
Section 1: Employment History - List your present or most recent employer first. Account for all times during the past 10 years, including periods of unemployment . Include your military experience and major volunteer experience. If you held significantly different positions with the same employer, list them separately. Attach additional sheet if necessary. In addition to resume, please provide all information below:
EMPLOYMENT DATES
 JOB TITLE
 MAY WE CONTACT YOUR CURRENT SUPERVISOR? YES    NO
JOB DUTIES:
LAST MONTH SALARY:
 HOURS PER WEEK
 REASON FOR LEAVING:
COMPANY NAME AND ADDRESS:
   SUPERVISOR'S NAME AND PHONE NUMBER:
EMPLOYMENT DATES
 JOB TITLE
 MAY WE CONTACT YOUR CURRENT SUPERVISOR? YES    NO
JOB DUTIES:
LAST MONTH SALARY:
 HOURS PER WEEK
 REASON FOR LEAVING:
COMPANY NAME AND ADDRESS:
   SUPERVISOR'S NAME AND PHONE NUMBER:
EMPLOYMENT DATES
 JOB TITLE
 MAY WE CONTACT YOUR CURRENT SUPERVISOR? YES    NO
JOB DUTIES:
LAST MONTH SALARY:
 HOURS PER WEEK
 REASON FOR LEAVING:
COMPANY NAME AND ADDRESS:
   SUPERVISOR'S NAME AND PHONE NUMBER:
Section 1: RN, LVN, PT Licensure / Nurse Practitioner Certification
CALIFORNIA LICENSE NUMBER:
   DATE ISSUED:
   EXPIRATION DATE:
LIST ALL STATES WHERE YOU HOLD/HELD AN RV, LVN, PT LICENSE AND STATUS:
   LIST ALL STATES WHERE YOU HOLD/HELD A NURSE PRACTITIONER LICENSE / CERTIFICATES AND STATUS:
Section 3: Education - List the schools you have intended including High School, Business, Technical, Military, Professional, College, and Graduate School.
SCHOOL NAME MAJOR UNITS GPA DEGREE
Section 4: Licenses, Certificates - List your professional licenses and certificates with the number, state, where issued and expiration date.
LICENSES AND CERTIFICATES:
Section 5: Other Skills - List other jo related skills you have such as knowledge of computer hardware. software applications and typing speed, machinery and/or other office, lab or scientific equipment you operate, foreign languages and/or medical terminology.
OTHER SKILLS:
Section 6: Required Information - Please check the appropriate box for each question.
1. HAVE YOU EVER BEEN CONVICTED OF A MISDEMEANOR OR FELONY (INCLUDING TRAFFIC VIOLATIONS)? (THIS INCLUDES ANY OFFENSE WHERE YOU WERE FOUND GUILTY, PLEAD GUILTY OR PLEAD NOLO CONTENDERE (NO CONTEST).
(A CONVICTION WILL NOT NECESSARILY DISQUALIFY YOU FROM CONSIDERATION FOR EMPLOYMENT)
YES    NO
2. HAVE YOU EVER BEEN ARRESTED AND ARE YOU OUT ON BAIL OR ON YOUR OWN RECOGNIZANCE STILL AWAITING TRIAL?
YES    NO
3. IF YOU ARE NOT A U.S. CITIZEN, DO YOU HAVE THE RIGHT TO WORK IN THE U.S. PERMANETALY?
YES    NO
TYPE OF VISA:
4. DO YOU HAVE A VALID CALIFORNIA DRIVER'S LICENSE
YES    NO
5. HAVE YOU EVER BE EMPLOYED BY THE STATE OF CALIFORNIA
YES    NO
6. HAVE YOU EVER BEEN RELEASED OR DISCHARGED FROM EMPLOYMENT OR RESIGNED TO AVOID SUCH RELEASE OR DISCHARGE?
YES    NO
IF YES, PLEASE PROVIDE DATE(S) AND CIRCUMSTANCES:
7. HAVE YOU EVER VIOLATED A STATE OR FEDERAL LAW OR RULE RELATING TO THE PRACTICE OF NURSING?
YES    NO
8. HAVE YOU EVER VIOLATED A STATE OR FEDERAL LAW OR RULE RELATING TO NARCOTICS OR CONTROLLED SUBSTANCE, OR OTHER SIMILAR REGULATIONS?
YES    NO
9. HAVE EVER BEEN FIRED FROM A NURSING-RELATED JOB IN THE LAST 5 YEARS?
YES    NO
10. ARE YOU UNDER INVESTIGATION OR ARE YOU THE SUBJECT OF ANY PENDING OR PAST DISCIPLINARY ACTION BY A NURSE-LICENSING AGENCY OR HAVE YOU EVER BEEN REFUSED A NURSE-LICENSING AGENCY OR HAVE YOU EVER BEEN REFUSED A NURSING LICENSE BY A STATE OR COUNTRY?
YES    NO
HAVE YOU EVER HAD A HEALTH-CARE RELATED LICENSE / CERTIFICATE TO PRACTICE / PRACTICE NURSING REVOKED, SUSPENDED, PLACED ON PROBATION OR OTHERWISE DISCIPLINED OR VOLUNTARY SURRENDERED IN ANY WAY?
IF YES, PLEASE EXPLAIN: