Employment Application
First Name
 Middle Name
Last Name
 Email ID
Nationality
Discipline
Current specialty Experience
years
How did you hear about us?
Have you applied with us before?
Yes   No
Grade your top three U.S. Regions:  
First Choice
 Second Choice
 Third Choice
Current address (Residence)
Street address
  
City/Town
 Best Time to Contact
State/Prov
 Home phone
- -
(Country Code - Area Code - Local)
Zip/Postal code
 Work phone
- -
(Country Code - Area Code - Local )
Country
 Cell/Mobile phone
- -
(Country Code - Area Code - Local)
Permanent address (if different)
Street address
 City/Town
State/Prov
 Zip/Postal code
Country
 Phone
- -
(Country Code - Area Code - Local)
Permit
Licensing Authority License # Exp. Month Exp. Year
Education
Secondary School Month/Year Graduated Diplomas/Degrees received
Provide Location
College/University name Month/Year Graduated Diplomas/Degrees received
Provide Location
Nursing School name Month/Year Graduated Diplomas/Degrees received
Provide Location
Have you Qualified?    
CGFNS Yes   No IELTS Yes   No
NCLEX Yes   No TOEFL Yes   No
TSE Yes   No    
In case of emergency
Person name to notify
Relationship
Street address
 City/Town
State/Prov
 Zip/Postal code
Country
 Phone *
- -
(Country Code - Area Code - Local )
Employment History
Please indicate all of your employment for the past ten(10) years, beginning with your most recent employer. Please list each facility in which you have worked.
Are you employed now? Yes   No
If so, may we contact your present employer? Yes   No
Other names under which you have been employed
Employer Information Add
If you have worked for more than one employer, please fillup details for the most recent employer under "Employer Record: 1" below and then click the add button above for filing up details of your additional employers - the most recent to be filled in first.
Employer Record: 1
Facility/employer
 Department/unit
Teaching Hospital
Yes   No 		Street address
City/Town
 State/Prov
Zip/Postal code
Country
Dates Employed From
 To
Specialty
 Position held
Supervisor's name and title
 Phone
- -
(Country Code - Area Code - Local)
Other supervisor?
 Phone
- -
(Country Code - Area Code - Local)
Patient Ratio
Number of Beds in Unit
Number of Beds in Facility
Reason for Leaving
Personal History
Has your professional license or certification ever been investigated or suspended?
Yes   No If yes, please give details and current status:
Have you ever been convicted of a crime other than a minor traffic violation? (Driving under the influence is not considered a minor traffic violation. Exceptions due to state employment law: Conviction(s) that have been sealed, expunged, eradicated, dismissed, or overturned and California Health &Safety Code §§11357(b) & (c), 11360(c), 11364, 11365, 11550 marijuana-related convictions over 2 years old, should not be revealed.)
Yes   No If yes, please give details and current status:
Have you ever been named as a defendant in a professional liability action?
Yes   No If yes, please give details and current status:
Do you have current authorization to work in the U.S.?(If you do not have current authorization to work in the U.S., Cambridge Healthcare will work with you to obtain this)
Yes   No If yes, please give details and current status:
 
 
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