NCP Vocational School

Document Sample
NCP Vocational School Powered By Docstoc
					NCP Vocational School
Application Form
                                                                                                                     POSITION

NAME        (Last)                                      (First)                                  (Middle)            DATE

                                                                                                                     HOME PHONE

ADDRESS     (number/Street/Apartment                    City                             State               Zip     SOCIAL SECURITY NUMBER

                                                                                                                     DRIVERS LICENSE NUMBER



IN CASE OF EMERGENCY, NOTIFY:
NAME                                                                                                                 PHONE



ADDRESS     (number/Street/Apartment                    City                             State               Zip     RELATIONSHIP




DO YOU HAVE ANY PHYSICAL CONDITION WHICH MAY LIMIT YOUR ABILITY TO PERFORM THE JOB APPLIED FOR?                    DESCRIBE



HAVE YOU BEEN CONVICTED OF A FELONY WITHIN THE LAST 7 YEARS?          IF YES, PLEASE EXPLAIN.



IF YOU ARE NOT A U.S. CITIZEN, HAVE YOU THE LEGAL RIGHT TO REMAIN PERMANENTLY IN THE U.S. (You will be asked to furnish documents)




MILITARY SERVICE (If related to position applied for)
BRANCH                                                             RANK                                                              RATE



ACTIVE FROM                        TO                              RESERVE FROM                             TO




Are you available to work               Full time           Part time          Temporary
Which shift do you prefer? _______. Which other shift are you able to work? _______How did you learn of NCP? ____________
On what date will you be available to start? _____________________________________
Give name, address and telephone number of two references who are not related to you and are not previous employers.
  *______________________________________________________________________________________________________
  *______________________________________________________________________________________________________
Date of last complete physical exam: ____________ Chest X-ray (for clinical instructors only) ____________ TB Test_____________
Describe any communicable diseases in the past 5 years ___________________________
Indicate languages you speak, read and write ____________________________________________________________________
HA ONLY: Are you State Certified? ______________ Certificate No. ____________________ Expiration Date ____________

RN/LVN ONLY
DATE AND STATE OF FIRST LICENSE                                              CURRENT CALIFORNIA LICENSE NUMBER                  EXPIRATION DATE



DO YOU CARRY YOUR OWN PROFESSION LIABILITY INSURANE                           CARRIER                  LIABILITY LIMITS         EFFECTIVE DATES




FOR OFFICE USE ONLY-DO NOT WRITE IN THIS BOX
RN/LVN LICENSE INSPECTED BY:                                               DATE:
      Education and Training Applicable to Position Applied For
                         NAME OF SCHOOL                       CITY, STATE AND ZIP                            MO/YR          GRAD        TYPE OF           MAJOR
                                                                                                             ATTENDED                   DEGREE            SUBJECT
                                                                                                                                        DIPLOMA OR
                                                                                                             FROM    TO     YES    NO
                                                                                                                                        CERTIFICATE
      COLLEGE,
      UNIVERISTY OR
      SCHOOL OR
      NURSING
      GRADUATE
      SCHOOL


      OTHER




      ANY
      WORKSHOPS,
      SEMINARS, OR
      COURSE
      HELPFUL TO
      NURSING

 RN/LVN: Have you completed your continuing education requirement? _________________
         If not, what steps have you taken to do so and when will you have it completed?___________

PRIOR WORK HISTORY (LIST IN ORDER APPLICABLE TO POSITION APPLIED FOR LAST OR PRESENT EMPLOYER FIRST)
 NAME                                                 PHONE                         NAME                                                     PHONE


  STREET ADDRESS                                                                     STREET ADDRESS


 CITY, STATE, ZIP                                                                   CITY, STATE, ZIP


 JOB TITLE                    SALARY           DATE WORKED       FROM      TO       JOB TITLE                   SALARY         DATE WORKED       FROM          TO


 REASON FOR LEAVING                                     SUPERVISOR                  REASON FOR LEAVING                                       SUPERVISOR


 NATURE OF WORK                                                                     NATURE OF WORK




 NAME                                                 PHONE                         NAME                                                     PHONE


  STREET ADDRESS                                                                     STREET ADDRESS


 CITY, STATE, ZIP                                                                   CITY, STATE, ZIP


 JOB TITLE                    SALARY           DATE WORKED       FROM      TO       JOB TITLE                   SALARY         DATE WORKED       FROM          TO


 REASON FOR LEAVING                                     SUPERVISOR                  REASON FOR LEAVING                                       SUPERVISOR


 NATURE OF WORK                                                                     NATURE OF WORK




 SPECIAL SKILLS AND QUALIFICATIONS
 ___________________________________________________________________________________________________________________________________
 ___________________________________________________________________________________________________________________________________
 ___________________________________________________________________________________________________________________________________
 _______________________________________________________________________

 May we contact the employers listed above?_____ If not, indicate which one(s) you do not wish us to contact and why ___________________________________

 Is there additional information relative to change of name necessary to enable NCP to check reference of prior employers?  Yes         No

 If Yes, explain _______________________________________________________________________________________________________________________

 AFFIDAVIT. I certify that the answers given by me to the forgoing questions are true and correct. I agree that NCP shall not be liable in any respect if my
 employment is terminated because of the falsity of statements, answers, or omissions made by me in this questionnaire. I also authorize the organizations, schools,
 or persons from all liability for any damage for issuing this information.

 Signed__________________________________________________________________________                        Date_____________________________________________________