RN Employment Application

One Stop Nursing Registry, LLC - Registered Nurse (RN) 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
Reference 3 Years Known
Signature and Acknowledgements
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.
Authorization Statement Signature
Authorization Statement Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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.
Confidentiality Statement Signature
Confidentiality 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.
Registration Acknowledgement Signature
Registration Acknowledgement 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
Privacy Policy Acknowledgement Signature
Privacy Policy Acknowledgement Date

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

First NameMiddle NameLast Name
Caregiver Agreement 2026 Signature
Caregiver Agreement 2026 Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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.
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
RN Job Description - Nurse, Reports To: Administrator
Job Title/Position: Nurse

Reports To: Administrator

JOB DESCRIPTION SUMMARY

The Nurse is responsible for the overall direction of home care services. Nurse establishes, implements and evaluates goals and objectives for home care services that meet and promote the standards of quality and contribute to the total organization and philosophy.

ESSENTIAL JOB FUNCTIONS/RESPONSIBILITIES

1. Coordinates and oversees all direct and indirect client services provided by caregivers.

2. Provides help in assessment, planning, implementation and evaluation of client and family/caregiver care to all caregivers as indicated.

3. Assists the Administrator in the preparation and administration of the organization's budget.

4. Interprets operational indicators to detect census changes and increases or decreases in volume, which could impact staffing levels, revenues or expenses.

5. Nurse assists Administrator in hiring, evaluation and termination of organization personnel.

6. Oversees the maintenance of client records, statistics, reports and records for purposes of evaluation and reporting of organization activities.

7. Assures proper maintenance of client records in compliance with local, state and federal laws.

8. Develops, implements and evaluates the orientation program for new organization personnel. Responsible for orientation of new organization personnel, either directly or by delegating to another staff member.

9. Assists in the development of organization goals. Develops, recommends, and administers Organization policies and procedures.

10. Assures compliance with all local, state and federal laws regarding licensure and certification of organization personnel.

11. In the absence of the Administrator, the Nurse will become the acting Administrator and will be vested with authority to act in behalf of the Administrator.

12. Other duties as assigned by the Administrator.

POSITION QUALIFICATIONS

1. Registered nurse with current licensure to practice professional nursing in the State.

2. Experience in a home care preferred.

3. Demonstrated ability to supervise and direct professional administrative personnel.

4. Ability to market and deal tactfully with customers and the community.

5. Must be a licensed driver with an automobile that is insured in accordance with state and/or Organization requirements and is in good working order.

6. Knowledge of business management and governmental regulations.

7. Has excellent observation, verbal and written communication skills. Will be required to communicate with clients and client’s family members when necessary.

8. Will be required to be stationary for long periods of time and work at a computer and/or on the phone.

9. May occasionally have to lift patients/clients if necessary.

SIGNATURE DATE
RN Job Description Signature
RN 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 RN 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.
Hepatitis B Vaccination Declination Signature
Hepatitis B Vaccination Declination Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
CPR/BLS certificate if held

Optional. A facility may separately require BLS.
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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.
Influenza Vaccination Declination Signature
Influenza Vaccination Declination Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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 - Registered Nurse (RN) Application Packet - DRAFT

Application for Employment

Signature and Acknowledgements

Authorization Statement

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

RN Job Description - Nurse, Reports To: Administrator

USCIS Form I-9

Service Area

Required Uploads

Hepatitis B Vaccination

Influenza Vaccination