PRN: Find Your Job: Licensed Nursing Personnel Application

Licensed Nursing Personnel Employment Application
Step 1 - Tell Us About Yourself
Today's Date (DD/MM/YYYY) / / Email Cell Social Security # Skill
Last Name First Name Middle Initial
Address 1
Address 2
City
State Other		Zip Code
Country Other

Home Phone
Message Phone

Are you at least 18 years old? Yes No
Will you work in a home with a pet? Yes No
Emergency Contact Name Phone#
Do you have access to public transportation? Yes No
Do you have access to a car? Yes No

Do you have a driver's license? Yes No
Driver's License Number	State	Expiration Date (DD/MM/YYYY) / /
Have you ever convicted* of a felony within the last 7 years? Yes No
If yes, please explain: *Conviction will not necessarily disqualify an applicant from employment

Professional License Number	State	Expiration Date (DD/MM/YYYY) / /
Do you have Professional Liability Insurance? Yes No If Yes, Who is Carrier?
Amount of coverage? $
Have you ever been bonded? Yes No

How were you referred to PRN?
I am fluent in the following languages:
Step 2 - Skill Inventory A
(Check the areas in which you have experience or training)
	Experience	Training
Head Nurse
Home Care
Staff Relief
Private Duty
Hospital
Nursing Home
Industrial Nurse
Public Health Nurse
School
Geriatrics
Orthopedics
Pediatrics
Peds-ICU
OB/GYN
Neonatal-ICU
Med-Surg
ICU-CCU
IV Therapy
Psychiatric
Oncology
Neurology
Other
Step 3 - Skill Inventory B
Check areas in which you are proficient:
Meds: IV Meds: Ztrack Meds: PO Meds: Interdermal Meds: IM Meds: Sub Q Meds: Heparin Lock Meds: Subclavian Dressings: Sterile Catheterization: Male Catheterization: Female Apnea Monitor Cardiac Monitor Fetal Monitor	EKG Kangaroo Pump Gastro Tube Feed Suctioning Trach Care Respirators MA-1 Respiratory Therapy IPPB IV's IV Pump Ostomy Care Hyperalimentation Oxygen Therapy































Other
What are your work preferences? What Days/Nights are you NOT available?
Step 4 - Education
High School School Name City State Graduated? Yes No Degree / Major College School Name City State Graduated? Yes No Degree / Major Other School School Name City State Graduated? Yes No Degree / Major






















Step 5 - Previous Employment
Please list your last 3 employers (temporary or permanent):
Dates (MM/YYYY): From To Name of Employer Address City State Phone Number Supervisor Position Salary Reason For Leaving
Dates (MM/YYYY): From To Name of Employer Address City State Phone Number Supervisor Position Salary Reason For Leaving
Dates (MM/YYYY): From To Name of Employer Address City State Phone Number Supervisor Position Salary Reason For Leaving
Step 6 - Personal References (No Family)
Name Address City State Occupation Phone Number Number of Years Known
Name Address City State Occupation Phone Number Number of Years Known
Name Address City State Occupation Phone Number Number of Years Known
Step 7 - Affidavit
I certify that answers given herein are true and complete to the best of my knowledge. I understand that, in the event of employment, false or misleading information given in my application or interview may result in discharge. I authorize investigation of all references and statements contained in the application for employment as may be necessary in arriving at an employment decision. I understand that after meeting all other job prerequisites, and after I am offered a job, employment will be contigent upon the satisfactory outcome of a medical examination. I understand that if I am offered employment, I will be working for PRN, on its payroll, at its client's premises. I understand that my employment may be terminated by PRN at any time, without liability to me for wages and salary except as have been earned by me at the date of such termination. I accept these terms and conditions After you've completed the application and accepted the terms, please type PRN in this box * to validate this form then click the "Send Form" button.
To apply online, please complete the application form, then click “Submit.” Then a PRN representative will contact you. We are an Equal Opportunity Employer.

Licensed Nursing Personnel Employment Application