PERSONAL INFORMATION:

Date

 Sex  

First Name

MI Last Name

Home Phone

Cell Phone Work Phone

Other Phone

Fax    

Present Address

City State / ZIP

E-mail

 Social Security Number D.O.B.
Age   Ht: Wt:
Nationality Languages Spoken 

Do you Drive?

Driver Lic. No. Exp. Date
Do you Have a Car ? Make/Year/Model
Are you Married ? Name of your Spouse
Do you have Children?  If so, how many and what are their ages?
       

EMERGENCY CONTACT INFORMATION:

Name of Contact Relationship
Phone Number        

 

QUALIFICATION:

 Registered Nurse (RN)   Certified Nurse Assistant (CNA)    
Licensed Vocational Nurse (LVN)   Experienced      
Certified Home Health Aide     Specialty Nurse:    
License Type:
Licence Number: Expir:

Certifications:
ACLS
PALS
NRP
LA Fire & Safety Card          

Education:
Name
Location
Year
Graduated Degree
High School:
College:
Course/Training:
Others:
         

We are an equal opportunity employer, dedicated to policy of nondiscrimination in employment on any basis includingrace, color, age, sex, religion or national origin.

Source Of Referral:
Name:
  
       
         
         

Availability:

Monday    
Tuesday    
Wednesday    
Thursday    
Friday    
Saturday    
Sunday    
       
Hospital: Private Duty:
Live In: Live Out:

 

For Specialty Nurses Only:

Med-Surg ICU/ CCU Peds NICU Psych Travel Nurse
PICU L&D Postpartum PACU ER Telemetry/DOU
                       
Do you have experience-transferring patients?            
If Yes, what is the maximum weight you can transfer? (Pounds)
Can you cook? What kind of food ?
Are you familiar with Kosher?  
Do you have any Allergies? If Yes, Explain 
What type of job do you desire? (Check all that apply):  
Elderly / Companion Handle Very ILL   Others
Nanny/Housekeeper Newborn Nurse    
       
Do you have experience with HIV? Will you work with HIV Patients?
       

ABILITIES (Check all conditions you have experience/knowledge with):

 Straight Catheter Blood Pressure Bedpan Stroke
Tracheotomy Care Diabetes Sugar Testing Diabetes Suctioning
Parkinson’s Insulin Injection Bedsore Ventilator
Colostomy Bag Psychological Bedridden Enemas
G or N/G Tube Fractures Wheelchair Wound Care
Catheter Male Paralyzed Walker IV Insertion
Catheter Female Nebulizer Orthopedic Heplock
Alzheimer’s/Mental Oxygen Blind Baths
Spinal Cord Injury Suppositories Cancer ALS
Heart Condition Diapers Hoyer Lift MS
Children Computers        
               

What other specialties/experience do you have (IV certified, phlebotomist, P.T. accounting, etc.)?

     
   
     

What are your personal interests (swimming, biking, playing games, listening to music, etc.)?

     
   
     

What other things would you like us to know about you?

     
   
     
How long have you been in the U.S.A?  
Have you ever been: Arrested Convicted Accused  
If yes, brief statement please:  
   
   

Have you ever worked in this agency before?  If yes, When? Date:

Are you presently employed? May we contact your present employer?
Present /Last Job: From To            
Name of Company: Position:            
Address:
Name of person/ supervisor: Contact Number:
If Deceased, contact:   Phone Number:            
Conditions of persons cared for:    Age   
Duties:
 
 

 

Second Job: From To            
Name of Company: Position:            
Address:
Name of person/ supervisor: Contact Number:
If Deceased, contact:   Phone Number:            
Conditions of persons cared for:    Age   
Duties:
 
 

 

Third Job: From To            
Name of Company: Position:            
Address:
Name of person/ supervisor: Contact Number:
If Deceased, contact:   Phone Number:            
Conditions of persons cared for:    Age   
Duties:
 
 

 

By signing this you hereby give AAA T.L.C Health Care, INC. or their representative, the right to do a
background & criminal check on you.

Name Date