Apply for LPN/RN employment application

Please fill out the form below and click Submit to submit your application for consideration. Fields with an asterisk (*) are required.

Summary
Title:LPN/RN employment application
ID:1001
Department:Nursing (LPN)
Resume
Resume:
Supported formats: Word, PDF, RTF, Text, and HTML.
  - or Upload from:
 
Contact Information
* First Name:
* Middle initial :
* Last Name:
* Address 1:
Address 2:
* City:
* State:
* Zip:
* Phone:
* Email:
* Social Security Number :
* Date of Birth :
* Drivers license State :
* Driver license number :
* Driver license expiration date:
Attachments
Cover Letter:
You can type in a Cover Letter or Copy/Paste from an existing document.
Application Information
* Are you a citizen of the United States?:
Yes   No
if no, are you authorized to work in the U.S.?:
Yes   No
* Have you ever worked for this company?:
Yes   No
if so, when?:
* Have you ever been convicted of a felony?:
Yes   No
if yes, explain:
Do you have a permanent residency card?:
Yes   No
Please enter your permanent residency card number::
Please enter the date your permanent residency card expires:
* How did you hear about Karen for Kids?
Indeed
Zip Recruiter
Monster
Employee Referral
Other
Employment Desired
* Desired rate::
* Date available:
* Shift preference (check all that apply):
  
  
* Select days you are able to work::
  
  
  
  
  
  
* Are you willing to work weekends?:
Yes   No
* Are you willing to work school cases?:
Yes   No
* (in miles) what is the maximum distance you are willing to travel for a case?:
* Do you have one full year of pediatric nursing experience within the last three years?:
Yes   No
* Was this one full year of pediatric experience as either an LPN or RN?:
Yes   No
* How many hours are you willing to work a week?:
* are you available for short notice shifts?:
Yes   No
* Choose your skill level (check all that apply):
  
  
* When was the last time you provided G-tube care?:
When was the last time you provided trach care? (if applicable):
When was the last time you provided Vent care? (if applicable):
* Please select the following G-tube skills you are proficient in:
  
  
  
  
  
  
  
  
  
  
  
Select the tracheostomy types you have experience with:
  
  
Please select the following trach skills you are proficient in:
  
  
  
  
  
  
Select the vent types you have experience with:
  
  
Education/Certificate
High School:
Address:
From:
To:
Degree:
Did you graduate?:
Yes   No
College:
Address:
From:
To:
Degree:
Did you graduate?:
Yes
No
Other:
Address:
From:
To:
Degree:
Did you graduate?:
Yes   No
Nursing License Information
* License State:
* License #:
* Exp. Date:
Nursing School Attended:
Nursing program completed::
* Graduation date:
Liability Insurance Information

Please note that your employment will not be denied if you do not have a current policy.

Insurance Company Name:
Insurance Coverage Amount:
Expiration Date:
Policy number:
Previous Employment
* Company:
* Phone:
Address:
* Supervisor:
Job Title:
Starting Salary:
Ending Salary:
Responsibilities:
From:
To:
Reason for leaving:
May we contact your previous supervisor for a reference?:
Yes
No
Company:
Phone:
Address:
Supervisor:
Job Title:
Starting Salary:
Ending Salary:
Responsibilities:
From:
To:
Reason for leaving:
May we contact your previous supervisor for a reference?:
Yes
No
Company:
Phone:
Address:
Supervisor:
Job Title:
Starting Salary:
Ending Salary:
Responsibilities:
From:
To:
Reason for leaving:
May we contact your previous supervisor for a reference?:
Yes
No
Character Reference Form

Reference 1

* Reference name:
* Phone:
* Address:
* City:
* State:
* Zip code:
Character Reference Form 2

Reference 2

* Reference name:
* Phone:
* Address:
* City:
* State:
* Zip code:
Employee Emergency Contact Form
* Allergies:

Emergency Contact Person (s)

* Name:
* phone:
* relationship:
* address:
Military Service
Branch:
From:
To:
Rank at discharge:
Type of discharge:
if other than honorable, explain:
Background Information
* Have you ever been dismissed from employment for drug or alcohol use?:
Yes   No
* Have you ever been convicted of a crime other than a routine traffic citation?:
Yes   No
If you answered YES to either question above, please explain:
Disclaimer and Signature
* I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release:
* Date:
Equal Opportunity Employment
We are an Equal Opportunity employer and do not discriminate on the basis of race, ancestry, color, religion, sex, age, marital status, sexual orientation, national origin, medical condition, disability, veteran status, or any other basis protected by law.

The information provided will be used for research, reporting, statistical purposes and to monitor legal compliance. To help us comply with these government requirements, please complete the following information.

Completion of this form is voluntary and will not affect your opportunity for employment or terms or conditions of employment if hired. We appreciate your cooperation.
Gender:
Female
Male
I Choose Not to Respond
Race/Ethnicity:
American Indian or Alaska Native (Not Hispanic or Latino)
A person having origins in any of the original peoples of North America and South America (including Central America), and who maintains tribal affiliation or community attachment
Black or African American (Not Hispanic or Latino)
A person having origins in any of the Black racial groups of Africa
Hispanic or Latino
A person of Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish culture or origin, regardless of race
Asian (Not Hispanic or Latino)
A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam
White (Not Hispanic or Latino)
A person having origins in any of the original peoples of Europe, North Africa, or the Middle East
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino)
A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands
Two or More Races (Not Hispanic or Latino)
All persons who identify with more than one of the above races
I Choose Not to Respond
Veteran Status: (Please check all that apply)
Individual with a Disability
An individual with a disability is a person who has a physical or mental impairment which substantially limits one or more of such person's major life activities, or who has a record of such impairment.
Vietnam Era Veteran
A person who 1) Served on active duty for a period of more than 180 days, and was discharged or released therefrom with other than a dishonorable discharge, if any part of such active duty occurred; a. in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or b. between August 5, 1964, and May 7, 1975, in all other cases; or 2) Was discharged or released from active duty for a service-connected disability if any part of such active duty was performed; a. in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or b. between August 5, 1964, and May 7, 1975, in all other cases.
Disabled Veteran
1) A veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or 2) A person who was discharged or released from active duty because of a service-connected disability.
War/Campaign/Expedition Veteran
A veteran who served on active duty in the U.S. military, ground, naval or air service during a war or in a campaign or expedition for which a campaign badge has been authorized.
Armed Forces Service Medal Veteran
A veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order No. 12985. To identify the military operations that meet this criterion, check your DD Form 214, Certificate of Release or Discharge from Active Duty.
Recently Separated Veteran
Any veteran during the three-year period beginning on date of such veteran's discharge or release from active duty in the U. S. military, ground, naval or air service.
I Choose Not to Respond

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