RN Employment Application

YOUR CONTACT INFORMATION

Salutation:

First Name:

Last Name:

Email Address:

Phone:

Address:

Address 2:

City:

State/Province:

Zip/Postal Code:

Country:

What is your employment preference?

Full-time Part-time Other

If "other" please list:

Hours Preferred:

Full-time Part-time Other

If "other" please list:

Are there any shifts you are unable to work?

Yes No

If "yes" please specify:

Fluent Languages:

Do you have an active licensure in your state of residence?

Yes No

Additional State Licensures:

How many years of clinical experience to you have?

5+ years 3-5 years 1-3 years Less then 1 year

How many years of telephone triage experience using electronic protocols do you have?

What is your knowledge of the Barton Schmitt/David Thompson guidelines?

Current working knowledge Working knowledge Familiar Not Familiar

Do you have a background in Disease Management?

Yes No

If "yes" please specify:

How would you rate your computer skills?

Expert Familiar Beginner Not Familiar

Do you have a home office set-up?

Yes No

Do you have a high-speed internet connection? (not dial-up)

Yes No

Preferred Method of Contact:

Please attach Your Resume (or paste into box):