Nurse Providers, Inc.
Application for Employment

AN EQUAL OPPORTUNITY EMPLOYER

Consideration is given without discrimination because of race, color, creed, sex, age and national origin, handicap or veteran status. Filling out this application is not a guarantee of employment.

APPLICATION FOR EMPLOYMENT

Name (last, first, MI):    Date:// 

Address:   

City:                    State:         Zip:

Phone: ()                     Social Security #  

Classification:    License #      Expiration: // 

If employed by NPI what date are you available to begin work?        // 

If you are not a U.S. citizen, do you have legal right to work in the U.S.?       yes  no 

Is there any reason you would be unable to safely perform the essential duties of the job
for  which you are applying (as described in the job description)?    yes  no 

EMPLOYMENT RECORD (Please list 3 most recent employers-Nursing positions only)

Employer:

Address:   

City:                    State:         Zip:

Phone: () Supervisor: 

Job Title:   

From: //  To: // 

Duties:

Reason for leaving:      Salary: $ /hour

 

Employer:

Address:   

City:                    State:         Zip:

Phone: () Supervisor: 

Job Title:   

From: //  To: // 

Duties:

Reason for leaving:      Salary: $ /hour

 

Employer:

Address:   

City:                    State:         Zip:

Phone: () Supervisor: 

Job Title:   

From: //  To: // 

Duties:

Reason for leaving:      Salary: $ /hour

 

EDUCATION RECORD: (Include all post high school education. List most recent schools first)

School:     Type:

City:             State:    Zip:  

Degree:  Graduated?   yes  no  

From: //  To: // 

 

School:     Type:

City:             State:    Zip:  

Degree:  Graduated?   yes  no  

From: //  To: // 

 

PROFESSIONAL REFERENCES
List two MOST RECENT supervisors or others who are familiar with your work performance.

Name:    Phone: ()

Address:   

City:            State:         Zip:

 

Name:    Phone: ()

Address:   

City:            State:         Zip:

 

PERSONAL REFERENCES (at least one)
(Reference can attest to your character and whom you have known at least five years.)

Name:    Phone: ()

Address:   

City:            State:         Zip:

Name:    Phone: ()

Address:   

City:            State:         Zip:

HAVE YOU EVER BEEN CONVICTED OF A FELONY WITHIN THE PAST 7 YEARS?
(A CONVICTION RECORD IS NOT NECESSARILY A BAR TO EMPLOYMENT.
EACH CASE WILL BE GIVEN INDIVIDUAL CONSIDERATION)   yes  no 

 

EMERGENCY INFORMATION

Employee’s Name:   Date: // 

In case of emergency, please notify:

Name:   

Phone: ()   Relationship:   

Address:   

City:              State:     Zip:

AND/OR

Name:   

Phone: ()   Relationship:   

Address:   

City:              State:     Zip:

 

Employee Signature: _______________________________________________________

Date: _________________________________________________________________

Please print this application, sign, and fax to (650)301-3257
or mail to:
Nurse Providers - application
355 Gellert Blvd., Ste. 152
Daly City, CA 94015

Proceed to other necessary online forms