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Please fill out the application below and we will contact you to discuss your situation in more detail.
(* indicates required field)
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First Name *
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Middle Name
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Last Name *
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Social Security Number *
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Address 1 *
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Address 2
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City *
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State *
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Zip *
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Primary Phone *
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Secondary Phone
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Fax
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Email Address *
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Emergency Contact Name
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Emergency Contact Address
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Emergency Contact Phone
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Drivers License State
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Drivers License Number
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Drivers License Expires
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Are you legally authorized to work in the United States? *
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Have you ever applied to or been employed by Alpha Nursing Service? *
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Have you ever been convicted of any misdemeanor or felony within the last 7 years? *
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How did you hear about us?
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Job Classification *
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, please specifiy
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Type of Employment Desired *
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Full time
Per diem
Inter. Visits
Contract
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Type of Shifts
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8 Hour Shifts
10 Hour Shifts
12 Hour Shifts
16 Hour Double Shifts
Other
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Shift Preference
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Day
PM
Night
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Professional Licensure / Certification
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1. State
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License Number
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Expiration Date
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2. State
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License Number
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Expiration Date
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3. State
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License Number
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Expiration Date
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Expiration Date - CPR/BLS
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Expiration Date - ACLS
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Expiration Date - NALS/NRP
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Expiration Date - PALS
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Expiration Date - IV CERT
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Expiration Date - CCRN
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Expiration Date - TNCC
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Employment History Clinical posiitions most recent first
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1. Employed From
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Employed To
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Employer
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Street Address
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City
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State
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Zip
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Supervisor's Name
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Supervisor's Telephone Number
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Your Title
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Unit Assigned
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Reason for Leaving
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2. Employed From
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Employed To
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Employer
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Street Address
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City
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State
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Zip
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Supervisor's Name
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Supervisor's Telephone Number
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Your Title
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Unit Assigned
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Reason for Leaving
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3. Employed From
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Employed To
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Employer
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Street Address
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City
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State
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Zip
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Supervisor's Name
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Supervisor's Telephone Number
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Your Title
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Unit Assigned
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Reason for Leaving
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4. Employed From
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Employed To
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Employer
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Street Address
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City
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State
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Zip
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Supervisor's Name
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Supervisor's Telephone Number
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Your Title
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Unit Assigned
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Reason for Leaving
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Education Information
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What is the highest clinical degree/certification received?
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1. School Name, City and State
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Area of Concentration
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Year Graduated from School
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Degree Type
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2. School Name, City and State
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Area of Concentration
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Year Graduated from School
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Degree Type
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Do you carry Professional liability insurance?
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If yes, any pending claims?
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Please Explain:
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What professional, trade, business or civic associations do you belong to?
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Special accomplishments, publications, or awards?
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Please select from the following, the skill/unit in which you have one year experience in the past 36 months as primary care:
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Nursing Home
M/S
Tele
ICU
ER
LTC
Peds
Psych
Detox
Clinic
Cardiac-S/D
CCU
Dialysis
Dr. Office
Hemotology
Hospice
L&D
Mother/Baby
NICU
OB
Oncology
OR
Ortho
PACU
Private Duty
PICU
Plastic Surgery
Rehab
RR
SICU
Trama
Other
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List other acute sub specialties for which you are qualified and would like to work
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Clinical Expierience (number of years)
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Assignment Preferences
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Location (where do you want to go)
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Describe your ideal position
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When are you available to start?
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Additional Comments
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References
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1. Name
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Phone
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Years Known
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Relationship
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Address
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2. Name
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Phone
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Years Known
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Relationship
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Address
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3. Name
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Phone
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Years Known
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Relationship
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Address
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Upload your Resume
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Attach File
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Copy and Paste your resume (4000 character limit - equivalent to 1 1/3 pages, 12 pt. type single spaced)
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Protecting our Employees - Sexual/Racial Harassment Policy
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All Alpha Nursing Service employees have the right to a work environment free of any form of sexual or racial harassment. Please report any sexually or racial harassment to Alpha Nursing Service immediately. Under no circumstances will an employee reporting harassment of any kind face disciplinary action for reporting the incident.
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Providing a Safe Workplace - Worker's Compensation Policy
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Alpha Nursing Service promotes a safe working environment for all of our employees. Any injury sustained while working on an assignment for Alpha Nursing Service, no matter how minor, is required to be reported to our office immediately. If you are unable to call, have someone contact us on your behalf. Injuries not reported immediately could lead to denied claims or result in lengthy delays for care and payment of related medical charges. Alpha Nursing Service will assist in making sure employees suffering injuries receive appropriate care.
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By checking "Continue" I agree to the following terms:
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I understand all the questions asked in this application and all the answers given by me are to the best of my knowledge true and complete. I understand that the omission, concealment, or misrepresentation of any information on this application or during any part of the employment process can be cause for immediate termination from employment or consideration of employment.
I give Alpha Nursing Service permission to use any and all information in my application to verify the information contained in this application. I furthermore authorize any persons listed on my application to provide answers to all questions asked by Alpha Nursing Service that will help evaluate my candidacy for employment. Alpha Nursing Service may conduct a criminal background investigation and perform a test for the use of illegal drugs or controlled substances in accordance with applicable laws and that my employment with Alpha Nursing Service will be contingent upon the results of such investigations and tests. I will and do hold harmless, Alpha Nursing Service, its agents, and all affiliated entities, as well as any person or institutions that provide Alpha Nursing Service with any information about me, from any and all liability whatsoever, resulting from any information received from our inquiries or any disclosure of such information as related to your application for employment with Alpha Nursing Service.
If employed by Alpha Nursing Service, I will not seek or accept employment, directly or indirectly in any capacity from any client/patient with whom I have been assigned to by Alpha Nursing Service, for a minimum of 90 days after the last day assigned to that client/patient by Alpha Nursing Service. Under no circumstances will I solicit these clients on my behalf nor on behalf of any other current or future employer(s). I will not transport patients in my automobile, nor am I to drive patients in the patient’s automobile without prior approval including written consent from Alpha Nursing Service and the patient or their representative.
Upon termination of employment I agree to return any and all Alpha Nursing Service property to the office including but not limited to, nursing bags, including all equipment and unused medical and nursing supplies, my I.D. badge, anything with patient information and any nursing forms.
If employed, I agree to abide by all Company policies and rules and I understand they are subject to change at any time for any reason without notice as deemed necessary by Alpha Nursing Service. Employment with Alpha Nursing Service is at will, for no definite period of time, and no communication, whether oral or written, by any representative of Alpha Nursing Service, at any time, can constitute a contract of or for employment. Employment can be terminated by either Alpha Nursing Service or me at any time, without cause or without advance notice.
I agree that Alpha Nursing Service and their agents have the maximum discretion permitted by law to administer, interpret, modify, discontinue or change all policies, procedures, benefits, or other terms and conditions of employment. I understand that my failure to adhere to any of Alpha Nursing Service’s policies and procedures or any of the above may result in my termination.
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Providing You Work - Terms of Employment
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Alpha Nursing Service does not guarantee work and can only offer work made available by our clients and patients and we reserve the right to cancel assignments as canceled by said clients and patients. Employees must call the office to request assignments and failure to call or otherwise contact Alpha Nursing Service to request work can be considered your voluntary termination of employment.
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I agree to the terms listed above *
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