Application Form

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Application Form

Personal Information

Name(Required)
Name(Required)
Address(Required)
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Do you Drive:(Required)

Employment Desired

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Have you applied to this Nurse Registry Before?(Required)
Are You Currently Employed:(Required)
If so, May We Contact your current employer:(Required)

General Information

Present Membership in National Guard or Reserves:

Education History

High School

University/College Undergraduate

University/College Graduate

Trade, Business or Correspondence School

Employment History (Most Recent Employment on top)

1

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Name(Required)
Address(Required)

2

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Name(Required)
Address(Required)

3

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Name
Address

Personal References (Names of three non-relative people known longer than 2 years)

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Name(Required)

2

Name(Required)

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Name

Physical Record

Do you have any physical disabilities that would prevent you from performing the work for which you are applying?
Have you ever been Injured?

Licenses/Certifications

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2

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3

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Availability Questionnaire

List the foreign language you speak, read, and write fluently(Required)
Areas Willing to Work In(Required)

Availability for Employment

Monday

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Tuesday

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Wednesday

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Thrusday

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Friday

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Saturday

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Sunday

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Willing to Work with Patients In

Able To Work With

Children
Adults

Authorization

“I certify that the facts contained in this application are true and complete to the best of my knowledge and understanding that, if employed, falsified statements on this application shall be put undergrounds of dismissal. I authorize the investigation of all statements contained herein and the references and employers listed above to give A Special Angel’s Touch Inc. all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result in utilization of such information. I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative. The waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.”
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