JOB APPLICATION FORM

JOB APPLICATION

BONAS-PM NURSES is an equal opportunity employer. This application will not be used for limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, of federal law. Should an applicant need a reasonable accommodation in the application process, he or she should contact a company representative.

Please fill out all of the sections below:

Applicant Information

Applicant Name:

Address:

City:

State and Zip Code:

Telephone Number:

Email Address:

Date of Application:

Employment Position

Position(s) applying for: RNs, LPNs/LVNs and CNAs.

How did you hear about this position?

What days are you available for work?

What hours or shift are you available for work?

If needed, are you available to work overtime?

On what date can you start working if you are hired?

Personal Information

Have you ever applied to or worked for BONAS-PM NURSES before?

YesNo

If yes, When

Are you a U.S. citizen or approved to work in the United States?

YesNo

What document can you provide as proof of citizenship or legal status?

Will you consent to a mandatory controlled substance test?

YesNo

Have you ever been convicted of a criminal offense (felony or misdemeanor)?

YesNo

If yes, please state the nature of the crime(s), when and where convicted and disposition of the case:

Personal Information

Please list below the skills and qualifications you possess for the position for which you are applying:

(Note: BONAS-PM NURSES complies with the ADA and considers reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. It is possible that a hire may be tested on skill/agility and may be subject to a medical examination conducted by a medical professional.)

Education and Training

School/College

Military:

Are you a member of the Armed Services?

What branch of the military did you enlist?

What was your military rank when discharged?

How many years did you serve in the military?

What military skills do you possess that would be an asset for this position?

Previous Employment

Employer Name:

Job Title:

Supervisor Name:

Employer Address:

City, State and Zip Code:

Employer Telephone:

Dates Employed:

Reason for leaving:

Employer Name:

Job Title:

Supervisor Name:

Employer Address:

City, State and Zip Code:

Employer Telephone:

Dates Employed:

Reason for leaving:

Employer Name:

Job Title:

Supervisor Name:

Employer Address:

City, State and Zip Code:

Employer Telephone:

Dates Employed:

Reason for leaving:

References

Please provide 2 personal and professional reference(s) below:

Reference

Contact Information

Additional Information:

Social Security Number

Date of Birth

A Copy of Government Issued ID

Professional Licences

Registered Nurse (RN) License #

State of Licensure

Licensed Practical Nurse (LPN) /Licensed Vocational Nurse (LVN) #

State of Licensure

Certified Nursing Assistant (CNA) #

State of Licensure

AT-WILL EMPLOYMENT

The relationship between you and the BONAS-PM NURSES is referred to as "employment at will." This means that your employment can be terminated at any time for any reason, with or without cause, with or without notice, by you or the BONAS-PM NURSES. No representative of BONAS-PM NURSES has the authority to enter into any agreement contrary to the foregoing "employment at will" relationship. You understand that your employment is "at will," and that you acknowledge that no oral or written statements or representations regarding your employment can alter your at-will employment status, except for a written statement signed by you and either our Executive Vice-President/Chief Operations Officer or the Company's President.

Applicant Signature:

Date:

EMPLOYMENT REFERENCE

I hereby authorize my past and present employers to provide information to BONASPM Nurses LLC, about my job performance while in their employment, permanent or temporary. I hereby release all employers and their representatives from all liabilities for issuing this information to BONASPM Nurses LLC. I also authorize BONASPM Nurses LLC to disclose the information to client facilities for which I have expressed an employment interest.

Signature

Accurate and thorough documentation

Adaptability to patient assignment

Attandance and Punctuality

Enthusiasm towards job

Communication Skills

Clinical Skills

Problem Solving Skills

Professional Appearance

Productivity

Professionalism

Quality of Work

Cooperation

Leadership Ability

Reasons For Leaving

TerminatedLay-offRedesignedTemporary Employee

Will you hire this healthcare professional again?

YesNo

Signature