: : CMS KATRA - Application : :

	On-Line Application
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Position Applying for:
Nursing

(Choose One)

Registered Nurse (RN)

Licensed Practical / Vocational Nurse

CNA

Surgery

Allied Health

Radiologic Technologist

Respiratory Therapist

Physical Therapist

If Other, please specify:

Advanced Practice

Nurse Practitioner

Certified Nurse Anesthetist

Certified Nurse Midwife

Physician Assistant

Personal Profile:

First Name:

Middle Initial:

Last Name:

Maiden Name:

Social Security #:

- -

E-Mail Address:

Permanent Phone:

- -

Current Phone:

- -

Pager/Cell:

- -

Best Time to Contact:

Referred By:

Address

Street Address:

City:

State / Province:

Zip / Postal Code:

Education:

High School:

School Name:

City:

State / Province:

Date Graduated:

(mm/dd/yyyy)

Type of Degree:

Vocational/Tech School:

School Name:

City:

State / Province:

Date Graduated:

(mm/dd/yyyy)

Type of Degree:

1. College / University:

School Name:

City:

State / Province:

Date Graduated:

(mm/dd/yyyy)

Type of Degree:

2. College / University:

School Name:

City:

State / Province:

Date Graduated:

(mm/dd/yyyy)

Type of Degree:

3. College / University:

School Name:

City:

State / Province:

Date Graduated:

(mm/dd/yyyy)

Type of Degree:

Licensure:

Are you Licensed?:

Yes No

Are you Registered?:

Yes No

License/Registry Eligible?:

Yes No

State / Province of Original
Licensure/Registry:

Active?:

Yes No

License #:

Employment Profile:

1. Employment:

Unit Manager:

Shift:

Phone:

- - Ext.

Employment Dates - From:

(mm/dd/yyyy)

Employment Dates - To:

(mm/dd/yyyy)

Facility:

Number of beds:

City:

State / Province:

Zip / Postal Code:

Teaching Facility?

Yes No

Trauma Facility?

Yes No

Staff Employee?

Yes No

Manager / Supervisor?

Yes No

Educator?

Yes No

Charge Experience?

Yes No

Part / Full Time:

Full Time Part Time

Specialty Unit Experience:

	Years:		Beds:
	Years:		Beds:
	Years:		Beds:

Nurses / PT Ratio:

2. Employment:

Unit Manager:

Shift:

Phone:

- - Ext.

Employment Dates - From:

(mm/dd/yyyy)

Employment Dates - To:

(mm/dd/yyyy)

Facility:

Number of beds:

City:

State / Province:

Zip / Postal Code:

Teaching Facility?

Yes No

Trauma Facility?

Yes No

Staff Employee?

Yes No

Manager / Supervisor?

Yes No

Educator?

Yes No

Charge Experience?

Yes No

Part / Full Time:

Full Time Part Time

Specialty Unit Experience:

	Years:		Beds:
	Years:		Beds:
	Years:		Beds:

Nurses / PT Ratio:

3. Employment:

Unit Manager:

Shift:

Phone:

- - Ext.

Employment Dates - From:

(mm/dd/yyyy)

Employment Dates - To:

(mm/dd/yyyy)

Facility:

Number of beds:

City:

State / Province:

Zip / Postal Code:

Teaching Facility?

Yes No

Trauma Facility?

Yes No

Staff Employee?

Yes No

Manager / Supervisor?

Yes No

Educator?

Yes No

Charge Experience?

Yes No

Part / Full Time:

Full Time Part Time

Specialty Unit Experience:

	Years:		Beds:
	Years:		Beds:
	Years:		Beds:

Nurses / PT Ratio:

Please List any other relevant work experience :
(Cut & Paste your Resume.)

Date of Availability:

(mm/dd/yyyy)

Legal Authorization

Legal Disclaimer

The statements made in this application are true to the best of my knowledge. I understand that any falsification will be the basis for disqualification of employment or termination of services. I authorize CMS KATRA to verify the information I have provided and to contact current and past employers and references concerning my ability, character and employment record. I release all such persons from liability for furnishing said information. I authorize CMS KATRA., as my employer, to release any medical information which may be relevant to my employment to their client facilities. By submitting this application to CMS KATRA., I authorize release of this information to all other affiliates of the Company and I acknowledge and agree that they may contact me using facsimile or any other means. Nothing contained in this employment application, or in the granting of an interview, is intended to create an employment contract between CMS KATRA and the applicant for either employment or for providing of any benefit. I understand that my employment may be dependent upon my passing a physical examination, criminal background investigation, clinical competency examination, and a pre-employment drug screen. If reasonable suspicion exists, or where warranted by circumstances, workplace conditions or contractual requirements, an additional drug screen may be performed at the discretion of CMS KATRA, Inc. or the medical facility to which I have been assigned. All offers of employment are made conditional upon the applicant's proving employment authorization and identity in accordance with the Immigration Reform and Control Act of 1986.

By checking the box I agree to this disclaimer.

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