© Critical Difference Inc. 2007
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APPLICATION
| CRITICAL DIFFERENCE INC. 1501 N. 9th AVE. PENSACOLA, FL. 32503 DATE________________ POSITION APPLIED:RN______ LPN______ CNA__ OTHER_________Name:_____________________________ Preferred 1st Name:___________ Address:_________________________________________________________________________ City,State,Zip:______________________ Home Phone#:______________ Other Phone :______________ Date of Birth:___/___/_____ S.S.#____/___/_____ U.S. Citizen_____ Referred by:_____________________________________Professional education: _________________________ From:_________________ List all states in which you are currently licensed or have been: (State) (License #) (Exp. Date) (Viewed & verified by) 1._______________________________________________________________________________________________________________________ 2.______________________________________________________________________________________________________________________ 3._______________________________________________________________Do you have Malpractice Insurance?_____ Insurance#_______________Company:______________________________Exp. Date:_________________ Clinical Areas Worked (list most recent first): 1.______________________________________ Years Experience:_______2._______________________________Years Experience:_______ EMPLOYMENT HISTORY List most recent employment first. Hospital:_____________________________________Address:________________________ City/State/Zip____________________ Position:_______________________Area of work:______________Immediate Supervisor:______________________ Phone _______________ Dates Employed (Mo, Yr): From______________ To______________Reason for leaving:_____________________________________________ Hospital:_____________________________________Address:________________________ City/State/Zip____________________ Position:_______________________Area of work:______________Immediate Supervisor:______________________ Phone _______________ Dates Employed (Mo, Yr): From______________ To______________Reason for leaving:_____________________________________________ Hospital:_____________________________________Address:________________________ City/State/Zip____________________ Position:_______________________Area of work:______________Immediate Supervisor:______________________ Phone _______________ Dates Employed (Mo, Yr): From______________ To______________Reason for leaving:_____________________________________________ Has your professional license ever been suspended or rvoked?_____Have you ever been discharged from a job or forced to resign?______Have you ever been convicted of a crime?______ If yes, explain: © Critical Difference Inc. 2004 ____________________________________________________________________________________________________________________________ (Preference) Hospital:1._______________ 2._______________ 3._______________ Shift: 1._______________ 2._______________ 3._______________ Area: 1._______________ 2._______________ 3._______________ Please fill in applicable expiration dates: C.P.R. _________ A.C.L.S.________ P.A.L.S.________ N.A.L.S.________ Specialty Certifications or Workshops: (i.e. C.E.N., C.C.R.N., etc) 1.______________ 2._____________ 3.______________4.______________ Have you ever applied for or received Worker'sCompensation?_______ Do you have any illness, injury or disability that would affect your ability to perform the job for which you are applying?________ List any surgery within past five years___________________________________________________________________________________________ Have you ever been treated for back injury?________ Hernia?______ Emotional illness?________ or Drug/Alcohol Abuse?________________ Have you ever been rejected life or health insurance?____________ If yes to any, please explain:______________________________________________________________________________________ Please notify in case of emergency: Name:________________________________Relationship:_______________ Address:__________________________________ Phone #: (H)__________ City/State/Zip____________________________ Phone #: (W)__________ I certify that all answers in this application are true. Any false statement of facts or information withheld may cause forfeiture of contractual agreement. I understand that C.D.I. will require a health assessment prior to my employment and periodically per state requirements. I authorize C.D.I. to contact former employers,licensing and any and all other agencies to verify and update employment history. I understand that C.D.I. does not pay for time and a half over forty (40) hours per week. Date:___/___/_____ Signature:_____________________________________ |
