* Name:

* Phone:

* Address:

* Do you have a legal right to work in the U.S.?

YesNo

* Are you over 18 years old?

YesNo

Position applying for with Pediatech Nursing:

* Current licensure:

RN    LPN    Other

If you selected Other, please specify:

License No.:

* State(s):

Expiration Date:

License No.:

State(s):

Expiration Date:

Certified as:

Nursing Asst.    HHA    CNA    Other

If you selected Other, please specify:

Certification received:

Course length:

* Word processor    10-key    None

* Computer background:

Microsoft Word    Excel    Outlook    No experience

Additional computer program/software knowledge or training:

Name and location of university, college, correspondence, trade, or other school:	Cert/Degree Received?	Type of Cert/Degree	Major
*	*	*	*

* May we contact your present employer?

YesNo

Below please list your present, or more recent employers, first.

Employer Name	From	To	Full-time or Part-time # hours per week
Address	Position	How long in position	Supervisor's name
City/State/Zip	Reason for leaving		Supervisor's phone

Describe the type of work and your duties:

Employer Name	From	To	Full-time or Part-time # hours per week
Address	Position	How long in position	Supervisor's name
City/State/Zip	Reason for leaving		Supervisor's phone

Describe the type of work and your duties:

Employer Name	From	To	Full-time or Part-time # hours per week
Address	Position	How long in position	Supervisor's name
City/State/Zip	Reason for leaving		Supervisor's phone

Describe the type of work and your duties:

Please list professional references familiar with your work and educational qualifications.

Name	Address	Phone	Relationship

PEDIATECH NURSING is an equal opportunity employer who does not discriminate against employees on the grounds of race, color, religion, age, sex, disability, sexual preference, marital status, or status with regard to public assistance.

I authorize inquiries to be made, including a background check, based on the information in this application to be used in consideration for employment. Former employers and individuals named herein are authorized to give information regarding my prior employment or character and they are hereby released from all liability for issuing such information.

I understand that this application and any other company documents are not contracts of employment. Any individual hired may voluntarily leave employment upon proper notice, and may be terminated by the employer at any time and for any reason.

If employed by Pediatech Nursing, it is understood that employment is conditional upon complying with the Immigration Reform and Control Act (IRCA) of 1986. I will furnish documentation/proof of my identity and my legal right to work and live in the U.S.

In understand that misrepresentation or omission of any facts will be cause for cancellation of consideration for employment, or if employed, will be cause for immediate dismissal.

* Signature of Applicant:

* Date: