Application for Registered Nurse for Preventative Health & Wellness Clinic
Full Name
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First Name
Last Name
Best phone number to reach you at?
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-
Area Code
Phone Number
Are you legally authorized to work in the US?
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Yes
No
Do you have a reliable means of transportation that will ensure your timely arrival at work at the beginning of your scheduled workday every day?
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Yes
No
What is your hourly salary expectation?(Must enter dollar amount, negotiable is not an answer)
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Are you able to work nights and weekends? (This is rare)
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Yes
No
When can you start?
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Do you smoke?
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Yes
No
Do you have any visible tattoos?
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Yes
No
Are you currently involved or planning on being involved in any other businesses, education (school) or activities during employment if hired that would either be a conflict of interest with the company or that would directly impact your ability to work your entire assigned shift?
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Yes
No
If yes, what type of business or activities will you be involved in and approx how much time do you plan to spend each week on this business or activity?
Educational Background
What is your highest level of education?
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Some highschool
Graduated highschool
Some college
Graduated college
Please list the school that you completed your highest level of education at.
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Please list any degrees, license, or certificates you have recieved.
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Do you have a valid Nevada RN license in good standing?
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Yes
No
Can you take and pass a drug test?
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Yes
No
Have you ever been convicted of a crime other than a traffic citation? (If yes, please explain.)
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Yes
No
Explanation
Previous Employment (Please list all previous employers)
Employer
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Position held
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Start date
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Month
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Day
Year
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End date
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Month
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Day
Year
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Job duties
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Reasons for leaving
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Employer
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Position held
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Start date
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Month
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Day
Year
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End date
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Month
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Day
Year
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Job duties
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Reasons for leaving
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Employer
Position held
Start date
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Month
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Day
Year
Date Picker Icon
End date
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Month
-
Day
Year
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Job duties
Reasons for leaving
Employer
Position held
Start date
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Month
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Day
Year
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End date
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Month
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Day
Year
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Job Duties
Reasons for leaving
Please explain in detail why you left your last place of employment. If you are still employed why are you thinking of leaving?
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Do you have any management experience? If so, please explain.
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Please explain all gaps in employment history.
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Do you have experience as a Registered Nurse?
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Yes
No
Do you know how to use a fax machine?
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Yes
No
Do you know how to scan documents?
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Yes
No
Experience-Please rate on a scale of 1-5
(1 being little to no experience 5 being a master at this skill)
Front Office
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1
2
3
4
5
Little to No Experience
Tremendous Experience
1 is Little to No Experience, 5 is Tremendous Experience
Additional details
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Are you comfortable talking on the phone?
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Yes
No
Additional details
*
Back Office
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1
2
3
4
5
Little to No Experience
Tremendous Experience
1 is Little to No Experience, 5 is Tremendous Experience
Additional details
*
Blood Draw (Phlebotomy)
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1
2
3
4
5
Little to No Experience
Tremendous Experience
1 is Little to No Experience, 5 is Tremendous Experience
Additional Details
*
Giving Shots
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1
2
3
4
5
Little to No Experience
Tremendous Experience
1 is Little to No Experience, 5 is Tremendous Experience
Additional Details
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Computer Skills
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1
2
3
4
5
Little to No Experience
Tremendous Experience
1 is Little to No Experience, 5 is Tremendous Experience
Excel
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1
2
3
4
5
Little to No Experience
Tremendous Experience
1 is Little to No Experience, 5 is Tremendous Experience
Word
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1
2
3
4
5
Little to No Experience
Tremendous Experience
1 is Little to No Experience, 5 is Tremendous Experience
Typing Speed (WPM) N/A or unknown is not an answer. You will best tested on typing speed prior to interview. If you are unsure, please take a test at www.typingtest.com
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Which is your typing speed based on?
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Looking at the keyboard
Looking away from the keyboard
Please list any languages you are fluent in besides English. (If none put N/A)
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Please list 3 current or former supervisors name, phone number, title and company as references. (Family, friends, and co-workers are not acceptable.)
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Do you have any other business talents outside of healthcare that you would like to share with us?
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Do you have any other leadership experiences or skills you would like to share with us?
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Please review our website completely www.vaccinecenter.com and describe your impressions of our clinic. (please write a minimum of 2 paragraphs)
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Please explain why you think you would be the best fit for our clinic.
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Please attache resume
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I attest that the above information is accurate. Any significant misstatements or exaggerations will result in termination if you are hired.
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I agree
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