Nursing Application | RN - Bluegrass Healthcare Staffing

Last Name First M.I. Maiden

Address     City State     Zip

Home phone #        Cell phone #       Email

Emergency Contact Contact phone #

Date Available:      Position: PRN 13 week    Referred by:

Have you worked for an agency before? Yes No If yes, with which company?

Can you, after employment, submit verification of your legal right to work in the United States? Yes No

Are you able to perform the basic functions of the position without reasonable accommodation? Yes No

If no, please explain:

Have you ever been convicted of a crime that would prohibit your employment at a healthcare facility? Yes No

If yes, please explain:

Are you willing to submit to a criminal background investigation? Yes No

Have you ever had disciplinary action taken against any license, or are you currently under investigation? Yes No

If yes, please explain:

As a condition of employment, you may be required to take and pass a drug and/or alcohol screen in any or all of the following circumstances:
Pre-employment     Post-accident     For cause random selection            Are you willing to consent to such tests: Yes    No

   Education:
                      School Major Degree
                      School Major Degree

   Specialty (most current experience first)
                           1.      Years of experience       As of
                           2.      Years of experience       As of
                           3.      Years of experience       As of
                           4.      Years of experience       As of

   Licensure
                    Professional License #     Expiration Date       State
                    Professional License #     Expiration Date       State

   Certifications (must fax or mail copy for your file)

                    Certification       Expiration Date
                    Certification       Expiration Date
                    Certification       Expiration Date
                    Certification       Expiration Date
                    Certification       Expiration Date

Bluegrass Healthcare Staffing is an Equal Opportunity Employer. All applicants are considered for employment regardless of age, race, gender, sexual orientation, religion, national origin, disability, marital status, or any other factor prohibited by law.

I certify that the information provided on this application is accurate. I understand that the giving of false information on this application will result in a refusal to hire or disciplinary action up to and including termination. Furthermore, I grant permission to any person, firm, corporation, or educational institution to release to Bluegrass Healthcare Staffing, LLC. any and all information regarding my past employment, background, credit history, education, motor vehicle records and criminal records. I understand and agree that if I am offered employment by the company, it will be on an at-will basis. This means that either I or the company may terminate the employment relationship at any time, for any reason, with or without cause or notice. I also understand and agree that only an officer of the company can enter into an agreement on any other terms and he/she can only do so in writing signed by him/her and me. I have read the above before signing this application.

I further understand and waive my right of privacy in this investigation and release and hold harmless Bluegrass Healthcare Staffing from any liability.

I agree that any decision to hire me is contingent upon the results of my report, and certify that all statements and answers on my application, resume, or interview are true and complete to the best of my knowledge. I understand that if any statements are false or that if information has been omitted, this will be cause for disqualification and immediate termination of my employment. If employed, I further authorize Bluegrass Healthcare Staffing to check my credit and/or conviction record, as needed, on a continuous basis as it relates to my employment.

I authorize Bluegrass Healthcare Staffing to release any employment records, including health records submitted to Bluegrass Healthcare Staffing to any customer of Bluegrass Healthcare Staffing for consideration of employment at customer facility.

*By typing your name below two times, you are electronically signing this application.

Last Name First Name Date
Last Name First Name Date

Application For Employment

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