Online Application

Please complete the application below. When finished, you will have the option to upload your Resume in Word (.doc) or PDF format. This information will allow us to determine which work opportunities are right for you and to get you placed in a great position ASAP!

(Fields marked with * are mandatory)

Name:*  
Address, City, State, Zip:*
Position Desired:*  Other:
Social Security#:  
Home phone:*  
Cell phone:  Other:
Email Address:*  
State of Licensure / Certification / Registry
State:*    #:*  Active                             Inactive
State:       #:     Active                             Inactive
State:       #:     Active                             Inactive
State:       #:     Active                             Inactive
     
Position Desired - check all that apply
Full Time          Part Time         Per Diem          Contract
Shift Availability / Preference - check all that apply
Days                 Evenings          Nights
     
Please pick a username and password for our online testing and benefits information:
 Username:*        Password:*
 You will receive an email once your user name and password is activated.
     
List any other names you may have worked under or used:  
     
Education and Experience    
Nursing School or Training School Name:*
City, State:*  
Degree Awarded:*  
Dates Attended:*  
     
College Name (if other than Nursing School):
City, State:  
Degree Awarded:  
Dates Attended:  
     
Vocational / Technical School Name:  
City, State:  
Diploma / Certification Awarded:  
Dates Attended:  
     
High School Name:  
City, State:  
Diploma-Awarded:  
Dates Attended:  
     
Expiration Date: 
Expiration Date: 
Expiration Date: 
Expiration Date: 
Other:  Expiration Date: 
Other:  Expiration Date: 
     
Have you ever worked for a temporary Agency Before?
Yes                 No    
Total Years of Health Care Experience:*
     
Please list months / years of experience in the appropriate areas of practice:
Acute Care:          Long Term Care:  
Ambulatory care: Other:                      
     
My experience is primarily in:
* months/years*
months/years  
months/years  
months/years  
months/years  
     
Work History and References
We will NOT CONTACT supervisors until we have confirmed your choice of references with you.
Provide Employment History, starting with your most current employer:

1. Facility Name:*
  From Month/year:* to month/year:*
  Address, City, State, Zip: *
  Position you held:*
  Immediate Supervisor Name:*
    Phone:*       
  Reason for Leaving:*

2. Facility Name:
  From Month/year: to month/year:
  Address, City, State, Zip:
  Position you held:
  Immediate Supervisor Name:
  Phone:          
  Reason for Leaving:

3. Facility Name:
  From Month/year: to month/year:
  Address, City, State, Zip:
  Position you held:
  Immediate Supervisor Name:
  Phone:          
  Reason for Leaving:

If you do not wish to use the supervisors listed above as references, please provide the names and telephone numbers of 3 other supervisors we can speak to. We will NOT CONTACT supervisors until we have confirmed your choice of references with you.

4. Name / Title:   Phone:
5. Name / Title:   Phone:
6. Name / Title:   Phone:

Military Status:*		  
Referal Source:  
If a current employee, who?:  
     
Are you able to perform all the essential functions of the position for which you are applying standard to the health care industry?*
Yes    
No, I am not able to perform all standard functions. Please explain: 
     
Has your License / Certification / Registration ever been investigated, suspended or revoked*
No         Yes, please explain      
Have you ever been convicted of a crime other than a misdemeanor*
No         Yes, please explain     
Have you been under investigation by federal or state authority for alleged violation of health care law?*
No         Yes, please explain     
Have you ever been the subject of a professional liability action?*
No         Yes, please explain     
     
I hereby certify that the information contained in this application is true and correct to the best of my knowledge, and I agree to have any of the information verified by ConTemporary Nursing Solutions, Inc. (CTS). I understand that any misrepresentation, falsification, or material omission of information on this application may result in my failure to receive an offer or, if I am hired, my immediate dismissal from employment.*
 I AGREE I DO NOT Agree  
     
I understand that any offer of employment is conditional upon proof of my identity, proof of my legal authority to work in the United States, verification of my licensure, certification or registration status, a satisfactory completion of my background and reference check, and the satisfactory completion of my post-offer substance test and medical examination.*
I AGREE I DO NOT Agree  
     
I authorize the references listed in the application, as well as other individuals whom CTS contacts, to provide any and all information concerning my previous employment and any other pertinent information they may have. Further, I release all parties and persons from any and all liability for damages that may result from the furnishing such information by CTS or any of its agents, employees, or representatives*
I AGREE I DO NOT Agree  
     
I agree that if I am hired, my employment with CTS can be terminated at will, with or without cause, and with or without notice, at any time, either at my option or at the option of CTS. If hired, I further agree that no employee or representative of CTS has the authority to modify the At-Will Employment Policy and Agreement, except for the President of CTS, and that any modification to the At- Will Employment Policy and signed Agreement must be in a written agreement signed by both the employee and the President of CTS. If hired, I further agree that this constitutes an integrated agreement with respect to the At-Will nature of the employment relationship, and that there may not be in the future any implied or oral agreement that in any way modifies the At-Will Employment Policy.*
I AGREE I DO NOT Agree  
     
ConTemporary Nursing Solutions, Inc. is an Equal Opportunity Employer and will not discriminate on the basis of race, color, religion, age, gender, national origin, marital status, disability (including HIV status) and liability for service in the US Armed Forces, or any other legally protected status. CTS will make any reasonable accommodation to known physical or mental limitations of a qualified applicant or employee with a disability unless the accommodation will impose an undue hardship on its operation.

When you submit this application you are affixing your electronic signature to the form. Corrections can be made by phone with the ConTemporary Nursing Solutions representative who will contact you.