GREAT LAKES HUMAN RESOURCES MANAGEMENT SERVICE
William S. Middleton Memorial Veterans Hospital
2500 Overlook Terrace, Madison, WI 53705
NURSING APPLICANT SUPPLEMENTAL INFORMATION
NAME: _________________________________________________ DATE: ______________
ADDRESS: ______________________________________________________________________
______________________________________________________________________
EMAIL ADDRESS_________________________________________________________________
PHONE: (Home): ______________________ (Work):________________
(Cell): ______________________
NUMBER TO CALL BETWEEN 8 A – 4 P__________________
POSITION APPLIED FOR: RN ___ GN ___ LPN ___ GPN ___ NP ___ Other(Specify)___________
DID YOU HAVE A CLINICAL EXPERIENCE HERE IN THE PAST OR AS A STUDENT?
YES ___ DATE & AREA____________________________________________________
NO ___
HAVE YOU WORKED AT ANOTHER VA? (Specify where and when):_____________________
_______________________________________________________________________________
IS THIS APPLICATION IN RESPONSE TO AN AD? yes___ no___
WHERE DID YOU HEAR ABOUT THIS VACANCY? (be specific):________________________
______________________________________________________________________________
ARE YOU SEEKING: FULL-TIME EMPLOYMENT _____
PART-TIME EMPLOYMENT _____
If part-time, how many hours per week? _____
SHIFT PREFERENCE: (Please mark all that apply. If you have more than
one, please let us know the order of preference.)
DAYS/ROTATING _____ PM’S _____
NIGHTS _____ OTHER (Specify) _____________________________________
PRACTICE AREAS OF INTEREST____________________________________________________
_______________________________________________________________________________
BACKGROUND – TYPE AND LENGTH OF PROFESSIONAL EXPERIENCES
(i.e. Nursing Home – 2 years, Med/surg – 1 year, etc. Attach additional sheets as needed, attach
updated resume. _________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
MONTH/YEAR YOU ARE AVAILABLE TO START EMPLOYMENT: _________________________
_______________________________________________________________________
WHEN IS THE BEST DAY/TIME TO SCHEDULE AN INTERVIEW?________________
_____________________________________________________________________________________________