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Last Name: Middle Initial:
First Name: Social Security No.:
Permanent Address:
City: State: Zip:
Phone: Cell/Pager:
E-Mail: Fax:
  Yes No
Are you 18 or older?
Do you have reliable means of Transportation to get to and from work?
Can you after employment, submit verification of your legal right to work in the United States?
Are you able to perform all of the tasks for the position in which you are applying for?
Have you ever been employed with Power Personnel before?
Have you ever applied at Power Personnel before?
Have you ever been convicted of a crime in the last 7 years?
If YES, please explain:    
Can you lift 25 pounds or more?
If NO, please explain:    
Employment Desired:
Position Desired: CNA LVN / LPN / LPT RN Other
Salary/Hourly Rate Desired:
What is your preferred work schedule: Travel Per Diem Permanent Full-Time
Date Available to Begin: (MM/DD/YY)
Are you presently employed? Yes No If YES, may we contact your present employer? Yes No
Education and Training
Nursing School:
City: State:
Date Graduated: (MM/DD/YY)
Degree Type: BSN A.A. ACLS Expiration: (MM/DD/YY)
CPR Expiration: (MM/DD/YY)

U.S Military Service: List Special Training or Skills:
If familiarity with foreign language is required for the position for which you are applying, please describe your foreign language skills:
License/Certificates: List any license or certificates you have which may help you to qualify you for the position you are applying:
Title: State Number: Date Expired:
Title: State Number: Date Expired:
List other equipment requiring special skills that you are familiar with:

Work History
List 4 Organizations you previously worked
Organization: Contact: Phone:
Address:
Dates Worked From: (MM/DD/YY) To: (MM/DD/YY)
Was this a travel assignment? Yes No Number of Beds?
 
Job Description:
Reason for leaving:
Starting Salary: Ending Salary:
 
Organization: Contact: Phone:
Address:
Dates Worked From: (MM/DD/YY) To: (MM/DD/YY)
Was this a travel assignment? Yes No Number of Beds?
 
Job Description:
Reason for leaving:
Starting Salary: Ending Salary:
---
Organization: Contact: Phone:
Address:
Dates Worked From: (MM/DD/YY) To: (MM/DD/YY)
Was this a travel assignment? Yes No Number of Beds?
 
Job Description:
Reason for leaving:
Starting Salary: Ending Salary:
---
Organization: Contact: Phone:
Address:
Dates Worked From: (MM/DD/YY) To: (MM/DD/YY)
Was this a travel assignment? Yes No Number of Beds?
 
Job Description:
Reason for leaving:
Starting Salary: Ending Salary:
Indicate Your Certifications / Expertise / Special Skills
ACRN AOCN CARN CCM CCRN CEN CFRN CGRN
CIC CNDLTC CNN CNOR CNS COCN CORLN CPDN
CPON CRNA CRNH CRNO CRRN CURN CWCN GNP
HNC OGNP PNP RN,C ANP CAPA CCCN CCNS
CDE CETN CGN CHN CLNI CNM CNNP CNRN
CNSN COHN CPAN CPNP CPSN CRNFA CRNI CRNP
CSN CVN FNP GPN OCN ONC RNC RN,SC
OTHER              
Resuscitation Credentials
ACLS CPR PALS BCLS NALS/NRP OTHER
Long Term Care:
Nursing Home Dementia/Alzheimer Unit Adult Day Center Skilled Nursing Unit
Blood Gas
Draw of Blood Arterial Line Insertion
Ventilator Management
Adult Neonatal / Infant Pediatric ECMO
Adult Critical Care
ICU Transplant Neuro ICU SICU CCU
Cardiac Cath
Adult Scrub Pediatric Recovery
Neonatal / Infant Sheath Team Circulate  
Adult Cardiac
CCU Transplant Cardiac Rehabilitation
Open Heart (CVICU) Telemetry / Progressive Interventional Unit
Hematology / Oncology
Floor Chemotherapy Administrative
Chemotherapy Certification Interventional Unit
Pediatric
Medical Surgery Neuro ICU Cardiac Unit Transplant ICU
CCU SICU Open Heart (CVICU) Trauma/ER  
OB/GYN
High-Risk Prenatal C-Section Scrub / Circulate Mother-Baby Unit
Labor & Delivery Post-Partum Transport
Neonatal
NICU (Level III) Special Care Nursery
Newborn Nursery (Level I) Open Heart (CVICU)
Attend Delivery Attend High Risk Delivery
Attend C-Section ECMO
Surgical / Operating Room
CRNA Open Heart Cosmetic/Reconstruction CVOR
Adult Infant / Neonatal IV Conscious Sedation Pediatric
General Surgery Transplant First Assistant  
Renal
Hospital Unit Hemodialysis Dialysis Center / Unit
Emergency Medicine
CEN ER Trauma Center / Unit Triage
Transport
CFRN Flight Pediatric
Ground Adult Neonatal
Long Term Care
CRNI Chemotherapy Cert. Chemotherapy Adm PICC
IC Term IV Conscious Sedation CLNI  
Doctors Office / Physical Practice Clinic
Adult Infant Back Office Coding
Immunizations Pediatric Front Office Medicare
Office / Practice Manager      
Ventilator Management
Adult Neonatal / Infant Pediatric ECMO
Occupational / Industrial Health
COHN
School Nurse
CSN Other School Nurse Certificate
Neuro
Spinal Rehab Center / Clinic Hospital Floor / Unit Acquired Brain Injury Unit/ Center
Gastrointestinal
Hospital Unit GI Lab
Psychiatric
Adult Adolescent
Pediatric Crisis Unit
MR / Development Facility Addiction / Rehab
Closed Unit Correctional / Prison
Others
Medical / Surgery Nursing Burn Unit
PACU / Recovery Room Pain Clinic / Center
Orthopedic Unit Sports Injury Clinic
Home Health Pulmonary Rehabilitation
Hospice Care Correctional Facility
Infectious Disease Quality Improvement
Sleep Study Lab (Polysomnography)  
Pre- Employment Certification

I certify that all statements given by me on this application, attachments hereto, or on my resume or other supplementary material are true and correct and without omission. I understand that falsified or omission of any information required on this form is sufficient grounds for immediate termination of my employment by Power Personnel, Inc. I agree to submit to legally permissible drug and/or alcohol testing upon request by the company. I recognize that the results of these tests may be used to determine my employment or continued employment.

I hereby authorize the schools, companies, former employers and all other persons named in this application to give any information regarding my employment, education, conviction records, or character. I hereby release Power Personnel, Inc and said school, agencies, companies, former employers, and all other persons named in this application from all liability for any damages resulting from issuing this information.

I certify that the foregoing answers to the questions asked in this application are true and correct to the best of my knowledge. I understand that falsification of information or misinformation may result in discharge at any time it becomes known by the agency.

I understand and agree that nothing contained in this employment application or in granting of any interview creates an employment contract between the agency and myself for either employment or for the providing of any benefit. No promises regarding employment have been made to me and I understand that no promises or guarantee is binding upon the agency unless made in writing prior to the date of this application. If an employment relationship is established, I understand that my employment will be terminated at will, that I will have the right to terminate my employment at any time, and that the agency will retain a similar right to terminate my employment at any time.

I further expressly agree that, with respect to the AT WILL employment relationship, this constitutes the full, complete and final expression of the parties' intent concerning the nature of any employment relationship between Power Personnel, Inc. and myself. I understand that any change to the AT WILL employment relationship and my agreement to submit employment related disputes to binding arbitration can only be made in a writing signed by me and the President of Power Personnel, Inc.

I have read and understand the above statements.

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