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______