Premier Nursing | Application

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Application

Join Us! Fill out the application form below
One of our experienced recruiters will contact you via phone or email to set up an appointment to physically visit one of our offices for an interview and to verify your employment eligibility in order for you to continue the application process.

Other Methods to Apply
Don't have time for an Online Application?

CREATE AN ACCOUNT
Username*: (required)
Password*: (required)
Confirm Password*: (required)

Classification
License No.*: (required)
Last Name*: (required)
First Name*: (required)
Middle Initial:
Phone Number*: (required)
Home Phone Number
Cell Phone Number:
Other:
E-Mail Address*: (required)
CURRENT ADDRESS:
City:
State/Province:
Zip/Postal Code:
Present Phone:
Will be at this location until:
Best time of day to reach you:
ADDITIONAL INFORMATION:
Referral Source:
Other (Please Specify):
Have you ever applied with us before?		Yes No
If so, when?:
CERTIFICATIONS:
Certification	Exp. Date	Certification	Exp. Date
ACLS		CEN
BLS		TNCC
PALS		CRRN
NALS		CCRN
CNOR		CHEMO
MAB		OCN
PART		CPI
OTHER
Related Courses/Certification (i.e., Chemotherapy, EKG, Balloon Pump, etc.)
All nurses who are joining Premier Nursing Services must have at least 2 years experience within the last 3 years, in an acute care facility. In order to ensure that nurses are not placed in an unsuitable environment or situation, all potential nurses are required to have at least 1 year of full time experience and relevant qualifications in his/her chosen field.
Burn		General Psychiatric
Orthopedic		Suicidal Psychiatric
Neurology		Geriatric Psychiatric
Metabolic		Adolescent
Gynecology		Adult
Gentio-urinary		Closed Unit
.
Medical surgical M/S		REH/rehabilitation
Intensive Care Unit / ICU		Respiratory
Neuro/Trauma / ICU		Cardio Vascular
Telemetry		HIV
PICU		Dialysis
Emergency Room / ER		Infection Disease
Operating Room / OR		Oncology
Recovery Room / RR
Out Patient
Sub Acute
Cardiology / Cath Lab
GI LAB
.
Postpartum
NICU
Labor & Delivery
Pediatric-Emergency Room
Wound Care
Have you ever had any disciplinary action taken against any of your licenses?		Yes No
Have you ever been named as a defendant in a malpractice claim?		Yes No
Have you ever been convicted of a felony?		Yes No
Do you hold a nursing license under any other name?		Yes No
If so, please list name:
Current Driver's License#
State:
Exp. Date:
Do you have the legal right to work in the United States and do you have documentation of that right?		Yes No
EMPLOYMENT HISTORY
May we contact your present employer?		Yes No
May we contact your previous employers?		Yes No
		Most Recent
Hospital:
City:
State:
Zip Code
Date employed:		From To
Position held:
Specialty unit(s) worked:
Shift:
Reason for leaving:
Average patient ratio:
Number of beds in unit:
Number of beds in hospital:
Was this a travel assignment?
Which agency?
Type of nursing:
Did you have a supervisory role?
Immediate supervisor:
Phone:
		Second Most Recent
Hospital:
City:
State:
Zip Code
Date employed:		From To
Position held:
Specialty unit(s) worked:
Shift:
Reason for leaving:
Average patient ratio:
Number of beds in unit:
Number of beds in hospital:
Was this a travel assignment?
Which agency?
Type of nursing:
Did you have a supervisory role?
Immediate supervisor:
Phone:
EDUCATIONAL BACKGROUND
College or University:
College or University City:
College or University State:
Graduated?		Yes No
Graduation Year
Diplomas, Degrees Received:
Nursing School or University:
Graduated?		Yes No
Graduation Year
Diplomas, Degrees Received:
Graduate School:
Graduated?		Yes No
Graduation Year
Diplomas, Degrees Received:
List any other skills or attributes which you feel make you exceptionally qualified for a position with this company:
2 PROFESSIONAL REFERENCES
Name 1
Phone Number
Name 2
Phone Number
EMERGENCY CONTACT
Name:
Relation:
Address:
City:
State:
Home Phone:
Work Phone:
ACKNOWLEDGEMENT
I hereby certify that the information contained in this application is correct to the best of my knowledge and understand that falsification of this information is grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery. I understand that nothing contained in the application or conveyed during any interview is intended to create an employment contract between me and Premier Nursing Services. I understand and agree that if I am employed; my employment is for no definite or determinable period and may be terminated at any time. I understand that my job duties and work hours may vary from my original preference. I authorize the persons or organizations listed in my application, to give all relevant information that concern my application for employment. I hereby release all such parties from all liability that may result from furnishing such information to Premier Nursing Services. I authorize Premier Nursing Services to request and receive such information. I waive the right to review any information received. I understand that any offer of employment is contingent upon verification of my nursing credentials, eligibility of employment, medical information furnished, results of drug screening, and criminal background check. I understand and agree that the results of these verifications may be made available to the clients of Premier Nursing Services.
* I agree

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MONDAY-SUNDAY
7AM – 9PM

Have Us Contact You
Don't have time for an Online Application? Or if you just have a few questions regarding employment opportunities, please fill out the form below and one of our recruiters will contact you.

First Name*: (required)

Last Name*: (required)

Phone Number*: (required)

Email Address*: (required)

Classification:

Years Of Experience:

Best Time To Call You:

Are you resident or citizen of the USA:
Yes No

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Downloadable documents:
REQUIRED FORMS
SKILL CHECKLIST

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