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CDI
APPLICATION
APPLICATION
Here are the forms that make up our application. You will need to fill out 2 Character Reference forms. They must
be filled out by an RN it doesn't have to be a supervisor. The Physician's Statement can be filled out by a
Physician's Assistant or a Nurse Practitioner or MD, and does not have to be a physical done for this application.
You may elect to apply as self employed if so please read the self employment info.
If you would be so kind as to send, or bring with you a copy of any references you might have, copies of your FL
lisc. CPR card, MMR records, Heptavax records, up to date TB test, as well as a copy of your CEU confirmation
for: Domestic Violence, Universal precaution/ HIV, Medical Errors and End of Life Care.
Michele Cleary, RN, DON
Critical Difference , Inc.
cdichell@cs.com
Fax 850-434-1515
Click the files below and open, then simply print and fill out
be filled out by an RN it doesn't have to be a supervisor. The Physician's Statement can be filled out by a
Physician's Assistant or a Nurse Practitioner or MD, and does not have to be a physical done for this application.
You may elect to apply as self employed if so please read the self employment info.
If you would be so kind as to send, or bring with you a copy of any references you might have, copies of your FL
lisc. CPR card, MMR records, Heptavax records, up to date TB test, as well as a copy of your CEU confirmation
for: Domestic Violence, Universal precaution/ HIV, Medical Errors and End of Life Care.
Michele Cleary, RN, DON
Critical Difference , Inc.
cdichell@cs.com
Fax 850-434-1515
Click the files below and open, then simply print and fill out