Critical Difference Inc

CRITICAL DIFFERENCE INC.

1501 N. 9th Ave., Pensacola, FL 32503 (850)477-1234

APPLICATION

POSITION APPLIED: RN__ LPN__ RESP TECH__ OTHER______

Name:______Preferred 1st Name:______

Address:______Home Phone#:______

City, State, Zip:______Other Phone:______

E- mail address: ______

Date of Birth: _____/_____/_____ S.S.#______/____/______U.S. Citizen______

Referred by:______

Professional education: ______From: ______

List all states in which you are currently licensed or have been:

(State) (License #) (Exp. Date) (Viewed & verified by)

1.______

2.______

3.______

Do you have Malpractice Insurance?_____ Insurance#______

Company:______Exp. Date:______

Clinical Areas Worked (list most recent first):

1.______Years Experience:______

2.______Years Experience:______

3.______Years Experience:______

4. ______Years Experience:______

EMPLOYMENT HISTORY

List most recent employment first.

1.Hospital:______

Address:______City/State/Zip______

Position:______Area of work:______

Immediate Supervisor:______Phone ______

Dates Employed (Mo, Yr): From______To______

Reason for leaving:______

2. Hospital:______

Address:______City/State/Zip______

Position:______Area of work:______

Immediate Supervisor:______Phone#:______

Dates Employed (Mo, Yr): From______To______

Reason for leaving:______

3. Hospital:______

Address:______City/State/Zip______

Position:______Area of work:______

Immediate Supervisor:______Phone:______

Dates Employed (Mo, Yr): From______To______

Reason for leaving:______

Has your professional license ever been suspended or revoked?_____

Have you ever been discharged from a job or forced to resign?_____

Have you ever been convicted of a crime?______If yes, explain:

______

______

(Preference)

Hospital:1.______2.______3.______

Shift: 1.______2.______3.______

Area: 1.______2.______3.______

Please fill in applicable expiration dates:

C.P.R. ______A.C.L.S.______P.A.L.S.______N.R.P.(N.A.L.S.)______

Specialty Certifications or Workshops: (i.e. C.E.N., C.C.R.N., etc)

1.______2.______3.______4.______

Have you ever applied for or received Worker's Compensation?______

Do you have any illness, injury or disability that would affect your ability to perform the job for which you are applying?_____ If yes to any, please explain:

______

List any surgery within past five years______

Have you ever been treated for back injury?______Hernia?______

Emotional illness?______or Drug/Alcohol Abuse?______

Have you ever been rejected life or health insurance?______

If yes to any, please explain:______

______

Please notify in case of emergency:

Name:______Relationship:______

Address:______Phone #: (H)______

City/State/Zip______Phone #: (W)______

I certify that all answers in this application are true. Any false statement of facts or information withheld may cause forfeiture of contractual agreement. I understand that C.D.I. will require a health assessment prior to my employment and periodically per state requirements. I authorize C.D.I. to contact former employers, licensing and any and all other agencies to verify and update employment history. I understand that C.D.I. does not pay for time and a half over forty (40) hours per week.

Date:____/____/_____ Signature:______

OFFICE USE ONLY

Date:___/____/_____ Interviewed by:______ID verified____

License viewed______License verified______TB test______

Physical exam______CPR______ACLS______References______