APPLICATION FOR EMPLOYMENT

For International Nurses Only

Please fill out this form as completely as possible. Use the Tab Key to move to the next field. If you have questions, please call our office.

REFERRAL SOURCE:

PERSONAL HISTORY

Surname Given/First name
Middle name    
Present Address
Present City Present Province
Present Phone Mobile Phone
Provincial address
Provincial city Province
Country Gender Male Female
Permanent address phone Cell Phone number
E-Mail address How often do you read your email?
Birth place Sex M F Male Female
Address
Do you have a passport? Yes  No Passport number
Place Issued Date Issued (mm/dd/yyyy)
Date of Expiration (mm/dd/yyyy)
Have you worked abroad? Yes  No What country?
What position? Length of time?
Did you complete the contract?
If No, Explain:

EDUCATION

Elementary School City:
Year Graduated
Secondary School City:
Year Graduated
Course of Study
College/university City:
Year Graduated
Course of Study
Graduate school City:
Year Graduated
Course of Study
Trainings/Seminars
List any Specialty Certifications

EMPLOYMENT HISTORY (PRESENT TO PREVIOUS)

Employer 1

Medical Facility

Phone
Address
Department/unit

Salary/month

Number of Beds in unit

Did you have a Supervisory Role

 Yes  No
Avg. Patient to RN Ratio    
Inclusive dates of employment from to

Position

Brief job description
Reasons for separation/ termination
Immediate Supervisor's Name

Supervisor's Position
May we contact this supervisor for reference? Yes  No

Employer 2

Medical Facility

Phone
Address
Department/unit

Salary/month
Number of Beds in unit

Did you have a Supervisory Role

 Yes  No
Avg. Patient to RN Ratio    
Inclusive dates of employment from    to

Position
Brief job description
Reasons for separation/ termination
Immediate Supervisor's Name Supervisor's Position
May we contact this supervisor for reference? Yes  No

Employer 3

Medical Facility

Phone
Address
Department/unit

Salary/month
Number of Beds in unit

Did you have a Supervisory Role

 Yes  No
Avg. Patient to RN Ratio    
Inclusive dates of employment from    to

Position
Brief job description
Reasons for separation/ termination
Immediate Supervisor's Name Supervisor's Position
May we contact this supervisor for reference?  Yes  No

Employer 4

Medical Facility

Phone
Address
Department/unit

Salary/month

Number of Beds in unit

Did you have a Supervisory Role

 Yes  No
Avg. Patient to RN Ratio    
Inclusive dates of employment from    to

Position
Brief job description
Reasons for separation/ termination
Immediate Supervisor's Name Supervisor's Position
May we contact this supervisor for reference?  Yes  No

Employer 5

Medical Facility

Phone
Address
Department/unit

Salary/month
Number of Beds in unit

Did you have a Supervisory Role

 Yes  No
Avg. Patient to RN Ratio    
Inclusive dates of employment from    to

Position
Brief job description
Reasons for separation/ termination
Immediate Supervisor's Name Supervisor's Position
May we contact this supervisor for reference?  Yes  No

SPECIAL QUALIFICATIONS

Have you taken the CGFNS examination? Passed  Failed Not Taken When?
Have you taken the NCLEX examination Passed  Failed Not Taken When?
Have you taken the TOEFL examination? Passed  Failed Not Taken When?
TWE Score Your PRC Rating
Have you taken the TSE examination Passed  Failed Not Taken When does it expire?
Total number of years RN Experience?
Are you CPR Certified? Yes  No When does it expire?
       
Have you ever had any disciplinary action taken against your RN license? Yes  No    
If yes, explain in detail.
Add any certifications and special equipment training to the left:

MISCELLANEOUS

Are you able to perform the essential functions of this position with or without reasonable accommodation? Yes  No
If No, please give details
Have you been convicted of a criminal offense by a court of law? Yes  No
If YES, please give details
Have you applied to any other agency before? Yes  No
If yes, have you signed a contract with an agency or employer yet Yes  No
Do you prefer to work in:

PROFESSIONAL REFERENCES

Name Position Phone
Name Position Phone

EMERGENCY CONTACT INFORMATION
(indicate complete contact, address and phone)

Name
Address
phone number

Cell phone
Relationship

 

Name
Address
phone number

Cell phone
Relationship

MEANS OF COMMUNICATION

What is the most reasonable medium to contact you
Where would you like important documents to be mailed:

RESUME

Please paste the contents of your Resume in the space below.

DECLARATION (READ CAREFULLY)

By AGREE in the box below I CERTIFY that all my statements in this application for employment are true and correct to the best of my knowledge and belief. I agree that if gainfully employed, any misrepresentation (s), falsification (s), and (or) omissions (s) of facts shall justify MY disqualification, dismissal, or repatriation from work.

Please choose I Agree from the box to the right if you agree to the above declaration.

IMPORTANT NOTICE: ImmQuest USA reserves the right to remove your application for employment from our data bank if you are not employed by any of our principals after one year from date of submission of this application.

PLEASE REVIEW BEFORE YOU PRESS THE SUBMIT FORM BUTTON!

Use for ImmQuest USA given by TravelKare.
Copyright © 2002 [TravelKare]. All rights reserved.
Revised: 09/09/02