* = Required Information
PERSONAL INFORMATION   Date
Name (Last Name First) *
 Social Security no. *
Present Address *
 City *
 State *
 Zip Code *
Permanent Address
City
State
Zip Code
Phone no. *
 Referred by
 
EMPLOYMENT DESIRED
Position
Date you can start
Salary Desired
Are you employed? YesNo If so, may we inquire of your present employer? YesNo
Ever applied to this company before?
YesNo		 Where?
When?
 
EDUCATION HISTORY
Name & Location of School Years Attended Did you graduate? Subjects studied
Grammar School
High School
College
Trade, Business or Correspndence School
 
GENERAL INFORMATION
Subjects of special study/research
Work or special training/skills
U.S Military or Naval service
Rank
 
FORMER EMPLOYERS (List below last four employers, starting with last one first)
Date
Month and Year		 Name & Address of Employer Salary Position Reason for leaving
From
To
From
To
From
To
From
To
 
REFERENCES   Give below the names of three persons not related to you, whom you have known at least one year.
Name Address Business Years known
 
JOB DESCRIPTION
Fundamental Purpose at the Job:
Staff Registered Nurse provide skilled nursing care to home bound patients in accordance with physician's orders and in compliance with state and federal regulations. Ensures quality and safe delivery of care provided by LVN and Home Health Aides.
Essential Functions:
      1. Participates and succeccfully completes agency orientation.
      2. Provides skilled nursing care in the patient's home as ordered by the attending physician in conjunction with the plan of care. A minimum of 7 visits per day as scheduled.
      3. Supervises LVN's and Home Health Aides in the Patient's Home.
      4. Complies with agency policies and procedures. Promotes and maintains an agency environment that is in compliance with federal, State and Local regulations.
      5. Submits clear and appropriate documentation in a timely manner.
      6. Communicates information effectively to physicians, supervisors and others and needed in a timely manner.
      7. Participates in case conferences leading the conference when assigned.
      8. Manages the utilization of supplies/equipment to enhance productivity and maximize costs controls.
      9. Participates in rotating on-call schedule.
Other Job Functions:
The above list reflects the essential functions and other job functions considered necessary of the job identified, and shall not be construed as a detailed description of all work requirements that may be inherent in the job, or assigned by supervisory personnel.
 
 
AUTHORIZATION
* “ I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.
        I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.
        I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.
        This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.”