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Registration: Shiftboard Webinar: Healthcare Shiftboard

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APPLICANT INFORMATION
 

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?
 Yes  No
Specialty Nurse
 Yes  No
Professional License
 Yes  No
Professional License State
Professional License Expiration
ACLS License Expiration
Other License?
 Yes  No
Drivers License State
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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Thank you for your interest!
 
 

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