One Stop Nursing Registry, LLC - Licensed Practical Nurse (LPN) Application Packet

One Stop Nursing Registry, LLC - Licensed Practical Nurse (LPN) Application Packet - DRAFT

Complete your application packet, availability, and required acknowledgements, and upload the requested documents to submit.
Organization: One Stop Nursing Registry, LLC | Address: 13319 SW 135th Ave, Miami, FL 33186 | AHCA License No. 30212618 | Phone: (786) 952-4767
Position Desired
Application for Employment
Last Name
First Name
Present Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City
State
ZIP
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Are you 18 years of age or older?
Have you ever been convicted of a felony?
If yes, please explain
Are you legally eligible to work?
Salary Desired
Days Available
Times Available
Maximum Hours per Week
Available to Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Work Interest
Availability Notes
Would you like to upload a resume instead of entering education history?
School Name
School Location
Years Attended
Graduated?
Subjects Studied
Would you like to upload a resume instead of entering former employer history?
From (Month/Year)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
To (Month/Year)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Employer Name and Address
Salary
Position
Reason for Leaving
Reference 1 Name

First NameMiddle NameLast Name
Reference 1 Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Reference 1 Business
Reference 1 Years Known
Reference 2 Name

First NameMiddle NameLast Name
Reference 2 Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Reference 2 Business
Reference 2 Years Known
Reference 3 Name

First NameMiddle NameLast Name
Reference 3 Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Reference 3 Business
Authorization Statement
By signing, you acknowledge falsified statements are grounds for dismissal, authorize investigation of statements, references, and employers, and that no representative can agree to employment for a specified period unless in writing signed by an authorized representative.
Reference 3 Years Known
Signature and Acknowledgements
Confidentiality Statement
By signing, you acknowledge medical records privacy and HIPAA compliance, that patients belong to One Stop Nursing Registry, LLC, and that you will not lure patients away.
Authorization Statement Signature
Authorization Statement Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Registration Acknowledgement
By signing, you acknowledge you must keep registration information current or the organization cannot provide potential clients, and you have received copies of the applicable rules for your profession. Organization: One Stop Nursing Registry, LLC, AHCA License No. 30212618.
Confidentiality Statement Signature
Confidentiality Statement Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Registration Acknowledgement Signature
Registration Acknowledgement Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hepatitis B Vaccination Declination Signature
Hepatitis B Vaccination Declination Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Influenza Vaccination Declination Signature
Influenza Vaccination Declination Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Attestation of Compliance with Background Screening - AHCA Form 3100-0008, May 2015
By signing, you attest under Sections 435.05(2) and 408.809(2), including disqualifying offenses, any exemption with decision letter attached if applicable, and any prior Level 2 screening in the last 5 years with results attached if applicable. Employer: One Stop Nursing Registry, LLC, AHCA License No. 30212618.
AHCA Form 3100-0008 Signature
AHCA Form 3100-0008 Title
AHCA Form 3100-0008 Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Privacy Policy Acknowledgement
By signing, you acknowledge the FDLE and FBI privacy policies for the Care Provider Background Screening Clearinghouse, including exchange, retention, and your right to challenge.
Privacy Policy Acknowledgement Printed Name

First NameMiddle NameLast Name
Caregiver Agreement 2026
This agreement contains all 14 terms, including non-exclusive placement, independent contractor status, self-employment taxes, 1099 over $600 per year, weekly pay, and Florida law. Registry Representative Signature is office-completed after review, not applicant-completed. Registry: One Stop Nursing Registry, LLC, AHCA License No. 30212618.
Privacy Policy Acknowledgement Signature
Facility Staffing Addendum
This addendum contains all 9 sections, including assignment acceptance, conduct, scope, attendance, facility policies, confidentiality, and non-solicitation for 12 months after your last assignment. Registry Signature is office-completed after review.
Privacy Policy Acknowledgement Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Caregiver Agreement 2026 Printed Name

First NameMiddle NameLast Name
Caregiver Agreement 2026 Signature
LPN Job Description - Reports To: RN
Job Title/Position: Licensed Practical Nurse

Reports To: RN

JOB DESCRIPTION SUMMARY

The Licensed Practical Nurse is responsible for providing direct patient care under the supervision of a registered nurse. Responsibilities include following the plan of care, providing treatments, and working collaboratively with the members of the team to help meet positive patient care outcomes.

ESSENTIAL JOB FUNCTIONS/RESPONSIBILITIES

1. Provides direct patient care as defined in State’s Name Nurse Practice Act.

2. Implements plan of care initiated by the registered nurse.

3. Provides accurate and timely documentation consistent with the plan of care.

4. Assesses and provides patient and family/caregiver education and information pertinent to diagnosis and plan of care.

5. Participates in coordination of home health services, appropriately reporting the identified needs for other disciplines to the registered nurse and/or Clinical Supervisor.

6. Uses equipment and supplies effectively and efficiently.

7. Participates in personal and professional growth and development.

8. Performs other duties as assigned by the registered nurse.

The above statements are intended to be a representative summary of the major duties and responsibilities performed by incumbents of this job. The incumbents may be requested to perform job related tasks other than those stated in this description.

POSITION QUALIFICATIONS

1. Graduate of an accredited practical nurse or vocational nursing program.

2. One year experience in hospital or home care setting is preferred.

3. Currently licensed as a licensed practical nurse or licensed vocational nurse in the state.

4. Complies with accepted professional standards and practice.

5. Demonstrates good verbal and written communication, and organization skills.

6. Must be a licensed driver with an automobile that is insured in accordance with state and organization requirements and is in good working order.

7. Possesses and maintains current CPR certification.

8. Prolonged or considerable walking or standing. Able to lift, position, or transfer patients. Able to lift supplies and equipment. Considerable reaching, stooping, bending, kneeling, or crouching.

SIGNATURE DATE
Caregiver Agreement 2026 Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Facility Staffing Addendum Printed Name

First NameMiddle NameLast Name
Facility Staffing Addendum Contractor Signature
Facility Staffing Addendum Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Facility Staffing Addendum Title
Title / License or Certification
LPN Job Description Signature
LPN Job Description Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
USCIS Form I-9
Form I-9 will be completed in the office at your in-person visit. Do not complete it online. The full I-9, employee Section 1 plus employer Section 2, current edition 01/20/25, expires 05/31/2027, is completed in person at the office visit, with Section 2 within 3 business days after the first day of employment after physically examining List A OR List B + List C.
Service Area
South Miami areas
Can work in South Miami area?
Other service areas
Reliable transportation?
Travel notes
Required Uploads
Photo ID copy - pre-check only, original examined in person for I-9 Section 2.

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Social Security card copy - pre-check only, original examined in person.

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Work Authorization Status
Work Authorization document copy - REQUIRED IF APPLICABLE ONLY. If you hold a work authorization document, for example an Employment Authorization Document, Permanent Resident Card, or other USCIS work authorization, upload a copy here. The original is examined in person at the office visit.

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Florida LPN license

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Background screening evidence

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Health statement - MUST state the applicant is free from communicable diseases and MUST be dated within the last 6 months before starting work. Older than 6 months, or missing that statement, does not satisfy it.

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Alzheimer's / dementia training certificate - must be from the Florida Department of Elder Affairs. Any other provider does not satisfy it.

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HIV/AIDS training evidence (one-time)

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Malpractice insurance proof - $1,000,000 if applicable.

Preferred if you carry a policy — not required to submit.
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Hepatitis B Vaccination
Mark ONE path: decline now at no charge and you may accept later, OR previously vaccinated and you agree to provide your vaccination record and antibody testing. Never complete both a declination and a record for the same vaccine.
CPR certification - Required

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Influenza Vaccination
By declining, you acknowledge the influenza facts, are declining now, and may change your mind if vaccine is still available. If previously vaccinated, upload the record INSTEAD of the declination, never both.
Resume

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Hepatitis B Status
Influenza Status
Hepatitis B vaccination record - upload INSTEAD of the Hepatitis B declination if vaccinated, never both

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Influenza vaccination record - upload INSTEAD of the Influenza declination if vaccinated, never both

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One Stop Nursing Registry, LLC - Licensed Practical Nurse (LPN) Application Packet - DRAFT

Application for Employment

Authorization Statement

Signature and Acknowledgements

Confidentiality Statement

Registration Acknowledgement

Attestation of Compliance with Background Screening - AHCA Form 3100-0008, May 2015

Privacy Policy Acknowledgement

Caregiver Agreement 2026

Facility Staffing Addendum

LPN Job Description - Reports To: RN

USCIS Form I-9

Service Area

Required Uploads

Hepatitis B Vaccination

Influenza Vaccination