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Online Application

General Information

First Name
Middle Name
Last Name
Home Phone
Other Phone
Email
Street Address
City
State
Zip
SS #
Step 1 of 8

License Information

Availability

Nurse's License Number
RN
LPN
State
Expires
   
Starting Date
Days Available
Shifts
Step 2 of 8

Person to notify in case of emergency

Name
Address
Phone
Relationship
   
Step 3 of 8

Check the functions and skills in which you are proficient

RN LPN   AIDE
CHARGE NURSE MEDICATION COURSE BLOOD PRESSURE
ICU ICU TPR'S
ICCU ICCU GIVE ENEMA
MED/SURG MED/SURG Are you a CNA or NE Registry?
OB OB Are you a Home Health Aide?
PEDS PEDS    
EMERGENCY RM EMERGENCY RM    
GERIATRICS PSYCH/MENTAL HEALTH    
    GERIATRICS    
Step 4 of 8

Education

HIGH SCOOL
Name: Location:
Dates Attended Diploma or Degree
Course or Study
NURSING SCHOOL
Name Location
Dates Attended Dimploma or Degree
Course os study
COLLEGE OR BUSINESS SCHOOL
Name: Location:
Dates Attended: Diploma or Degree
Course of Study:
Step 5 of 8

Miscellaneous

Car Available  
Driver's License  
Ever Denied a Bond  
Ever Convicted of a Crime  
Worked for a Temp. Service Before  
How did you hear of AMHS
Step 6 of 8

Employmnent History

Job 1
Employer:   From:   To:   Address:  
Supervisor & Phone: Position:
Wages: Reason for Leaving:
Job 2
Employer:   From:   To:   Adress:  
Supervisor & Phone: Position:
Wages: Reason for Leaving:
Job 3
Employer:   From:   To:   Address:  
Supervisor & Phone: Position:
Wages: Reason for Leaving:
Step 7 of 8

Confirm

I certify that the above is accurate and truthful.  I understand that supplying false or inaccurate information can be grounds for not hiring an applicant, and/or termination.  All application and resume data are subject to verification.


I hereby authorize All Midlands Health Services to verify my education, licenses, motor vehicle records and criminal conviction records.


I also authorize All Midlands Health Services to request, and also authorize each former employer and person given as reference to answer all questions that may be asked, and give all information that may be necessary in connection with this application or concerning me or my work.



Submit this Application


All Midlands Health Services is an equal opportunity employer.