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APPLICANT INFORMATION
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First Name
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Last Name
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Email
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Zip/Postal Code
Primary/Home Phone
Mobile Phone
Address
City
State/Province
Alabama
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American Samoa
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Armed Forces Americas
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District of Columbia
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Texas
U.S. Minor Outlying Islands
Utah
Vermont
Virgin Islands of the U.S.
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Nursing License
Professional License
ADDITIONAL INFORMATION
ARE YOU LEGALLY ELIGIBLE FOR EMPLOYMENT IN THE UNITED STATES?
Yes
No
DO YOU HAVE ANY CURRENT INDICTMENTS AND/OR PENDING CRIMINAL CHARGES AGAINST YOU?
Yes
No
HAVE YOU EVER REGISTERED WITH OR BEEN EMPLOYED BY LEGACY HEALTHCARE SOLUTIONS BEFORE?
Yes
No
HAVE YOU EVER BEEN CONVICTED OF A CRIME?
Yes
No
DO YOU HAVE ANY RESTRICTIONS, WHICH WOULD INTERFERE WITH YOUR ABILITY TO PERFORM THE ESSENTIAL DUTIES OF THE POSITION FOR WHICH YOU HAVE APPLIED?
Yes
No
DO YOU HAVE A RELIABLE MEANS OF TRANSPORTATION TO JOB ASSIGNMENTS?
Yes
No
ARE YOU CURRENTLY WORKING UNDER A CONSENT ORDER OR WITH A RESTRICTED LICENSE FROM ANY STATE LICENSING BODY OR BOARD?
Yes
No
DO YOU HAVE PROFESSIONAL LIABILITY INSURANCE?
Yes
No
Licensure
HAS YOUR PROFESSIONAL LICENSE, CERTIFICATE OR REGISTRATION EVER BEEN SUBJECT TO DISCIPLINARY ACTION BY ANY STATE BOARD OR BODY, SUCH AS BY REPRIMAND, SUSPENSION, REVOCATION, CONSENT ORDER, VOLUNTARY SURRENDER OR FINES?
Yes
No
HAS A LICENSE/CERTIFICATION EVER BEEN ISSUED IN ANOTHER STATE
Yes
No
DO YOU HAVE A CURRENT, VALID LICENSE/CERTIFICATION?
Yes
No
LICENSE/CERT. TYPE
ARE YOU AWARE OF ANY PENDING COMPLAINTS OR INVESTIGATIONS AGAINST YOUR PROFESSIONAL LICENSE, CERTIFICATE OR REGISTRATION IN ANY STATE TO THE BEST OF YOUR KNOWLEDGE?
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No
Specialty Nurse
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No
Professional License
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No
Professional License State
Please Select
Alabama
Alaska
Arizona
Arkansas
California
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Connecticut
Delaware
District of Columbia
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Hawaii
Idaho
Illinois
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Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Professional License Expiration
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
1
2
3
4
5
6
7
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Year
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2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
ACLS License Expiration
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
Other License?
Yes
No
Drivers License State
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
License Number
Education
School Name
School Location
School Degree or Level
School Graduation/Certificate Year
School Name
School Location
School Degree or Level
School Graduation/Certificate Year
Emergency Contact
Emergency Contact Name
Emergency Contact Phone
Emergency Contact Relationship
References
First Reference Name
First Reference Relationship
First Reference Phone
Second Reference Name
Second Reference Relationship
Second Reference Phone
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