NSMC Employment Application

Employment Application
Click the link below to download a printable job application.

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Position Applied for*
Applicant Information
Last*
First*
M. I.*
Date*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Email*
example@example.com
Date Available*

MonthDayYear
Date
Desired Salary $
Are you at least 18 years of age?*

YesNo
Have you ever applied to work here before*

YesNo
If yes, when?

MonthDayYear
Date
Have you ever worked here before?*

YesNo
If yes, when?

MonthDayYear
Date
Do you have a reliable means of transportation?*

YesNo
Do you have other obligations that might cause you to miss work?*

YesNo
If yes, please explain.
Have you ever been convicted of. acrime or plead guilty to a felony?*

YesNo
If yes, please explain
Are you a U.S Citizen or an alien who has the legal right to work in the U.S.?*

YesNo
Do you have any relatives that currently work at NSMC?*

YesNo
If yes, who?
Did anyone refer you to this position?*

YesNo
If yes, who?
License and Registration Information for Nurses and Professional Individuals
State
License Number
Expiration Date

MonthDayYear
Date
Type
State
License Number
Expiration Date

MonthDayYear
Date
Type
State
License Number
Expiration Date

MonthDayYear
Date
Type
State
License Number
Expiration Date

MonthDayYear
Date
Type
Shift Availability - Check all that you are willing to work*

DayEveningNightWeekendHolidayPRNPart-TimeFull-Time
Education
High School:*
From*
To:
Did you graduate?*

YesNo
Diploma
College
From
To
Did you graduate?

YesNo
Degree
Other
From
To
Did you graduate?

YesNo
Degree
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?

YesNo
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?

YesNo
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?

YesNo
References

Please list three professional references
Full Name*
Relationship*
Company*
Phone*
Address*
Full Name*
Relationship*
Company*
Phone*
Address*
Full Name*
Relationship*
Company*
Phone*
Address*
Disclaimer and Signature
I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, / understand that false or misleading information in my application or interview may result in my release.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Employment Application

Applicant Information

License and Registration Information for Nurses and Professional Individuals

Education

Previous Employment

References

Disclaimer and Signature