Premier Nursing Service

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Tell Us About Yourself
One of our experienced recruiters will contact you via phone or email to continue the application process.

First Name*

Middle Initial

Last Name*

Phone Number*

Cell Phone Number

Pager Number

Email Address*

Address

Apt #

City

State

Zip

Classification

How did you hear about
Premier Nursing Services?

Please Check Appropriate:
Employee	Flyer Post Card
Friend	Nurse Week Magazine
Newspaper	Yellow Pages
Other	Search Engine
If you were referred by a specific individual, publication or search engine please specify below:

Shifts you would
like to work for?

Please Check Appropriate:
7am - 7pm	7am - 3pm
3pm - 11pm	7pm - 7am
11pm - 7am

Has your license (in any jurisdiction that you may have been licensed in) ever been investigated, suspended, or revoked?

Yes	No
If yes, please detail the dates, circumstances, and the final outcome:

Has there been a complaint filed against your license?

Yes	No
If yes, please detail the dates, circumstances, and the final outcome:

Do you have any malpractice or negligence suits pending?

Yes	No
If yes, please give details of the suit and its current status:

Have you (in the past seven years) been convicted of a felony, pleaded no contest to a felony, pleaded guilty to a felony or been found guilty of a felony? (Include all such instances even if adjudication was withheld)

Yes	No
If yes, please give dates and details.

Attach a resume:

(Word, PDF, or Plain Text Document)

Best Time(PST)
to Contact You

Start Date
(mm/dd/yyyy)

Interested In:

Travel Long Term Per-diem