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Nursing Assistant Personnel Employment Application |
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Step 1 - Tell Us About Yourself
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Last Name
First Name
Middle Initial
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Address 1
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Address 2
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City
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State
Zip Code
Other
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Country
Other
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Home Phone
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Message Phone
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Are you at least 18 years old?
Yes
No
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Will you work in a home with a pet?
Yes
No
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Do you have access to public transportation?
Yes
No
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Do you have access to a car?
Yes
No
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Do you have a driver's license?
Yes
No
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Driver License Number
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State
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Expiration Date (DD/MM/YYYY)
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Have you ever convicted* of a felony within the last 7 years?
Yes
No
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If yes, please explain:
*Conviction will not necessarily disqualify an applicant from employment
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Training Certificate Number
Expiration Date (DD/MM/YYYY)
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Have you ever been bonded?
Yes
No
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How were you referred to PRN?
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I am fluent in the following languages:
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Step 2 - Skill Inventory A
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(Check the areas in which you have experience or training) |
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Experience |
Training |
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Hospital |
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Nursing Home |
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Private Home |
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Meal Preparation |
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Special Diets |
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Spinal Cord Injury |
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CVA |
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Geriatric Care |
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Pediatric Care |
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Psychiatric Care |
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AIDS Care |
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Mother/Child Care |
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Mental/Retardation Care |
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Oncology/Dying Patient Care (Hospice) |
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Other
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Step 3 - Skill Inventory B |
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Check areas in which you are knowledgeable: |
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Transfer ROM
Bathing
TPR
Blood Pressure
Dressing Change Unsterile
Warm/Cold Compresses
Ostomy Care
Foley Care
Supervise Meds
Intake and Ouput
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What are your work preferences?
What Days/Nights are you NOT available?
Are you available for live-in assignments?
Yes
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Step 4 - Education |
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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
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Step 5 - Previous Employment |
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Please list your last 3 employers (temporary or permanent): |
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Dates (MM/YYYY): From
To
Name of Employer
Address
City
State
Phone Number
Supervisor
Position
Salary
Reason For Leaving
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Dates (MM/YYYY): From
To
Name of Employer
Address
City
State
Phone Number
Supervisor
Position
Salary
Reason For Leaving
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Dates (MM/YYYY): From
To
Name of Employer
Address
City
State
Phone Number
Supervisor
Position
Salary
Reason For Leaving
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Step 6 - Personal References (No Family) |
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Name
Address
City
State
Occupation
Phone Number
Number of Years Known
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Name
Address
City
State
Occupation
Phone Number
Number of Years Known
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Name
Address
City
State
Occupation
Phone Number
Number of Years Known
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Step 7 - Affidavit |
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Are you capable of performing in a reasonable manner the activities involved in the job or occupation for which you have applied?
(A description of the activities in such a job is attached. Do not answer this question unless you have been informed about the requirements of the job for which you are applying.)
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 "Submit" button.
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To apply online, please complete the application form, then click “Submit.” Then a PRN representative will contact you.
We are an Equal Opportunity Employer.
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