Moore Special Nurses - Job Application

Please Complete The Form Below And Press The Submit Button At The Bottom:

Incomplete Applications Will Not Be Processed.


Full Name		Address
City		State
Country		Social Security#
Zip		E-mail
Home Phone

Position you are applying for:

LPN

Live-In Homemaker

MSW

EXPERIENCE		INTERESTED IN		AVAILABILITY
	Pediatrics		Pediatrics		Days
	Adult		Adult		Nights
	Private Duty/Vent		Private Duty/Vent		Evenings
	Intermittent/Visits		Retirement Community		Weekends
	Infusion				Part Time
	Retirement Community				Full Time
	Respiratory Therapy/EEG
	Sleep Lab Tech

Preferred Location(s)/site (hospitals, nursing homes, clinics) of interest to work.


Location 1		Address 1
Location 2		Address 2
Location 3		Address 3

Professional Licensure


Type		Number
Duration		Current States
Expiration

Applicant Declaration


Are you 16 or older		Are You Eligible to work in the United States

Have you ever been convicted, plead guilty to a crime? This includes misdemeanors (except parking violations) gross misdemeanors and felonies. A conviction, guilty plea or no contest will not necessary disqualify you for employment consideration. Yes No If yes give dates and expiration (where, when, etc.).

Have you ever been excluded from the Medicare or Medicaid program for conduct that would constitute a misdemeanor, gross misdemeanor or felony under the law. Yes No If yes give dates and expiration (where, when, etc.).

Have you ever been disciplined by professional or state ethics or licensing board?. Yes No If yes give dates and expiration (where, when, etc.).


How did you find out about our company positions?

Educational Information


High Education		Diploma, Commercial/Technical Program
Address		Address
City		City
Did You Graduate		Did You Graduate

College or University		Graduate School
Address		Address
City		City
Did You Graduate		Did You Graduate

Employment Information


Employer 1		Address
City		State
Zip
Supervisor Name		Supervisor Phone
Start Date		End Date
Position		Avg Hours Per Week
Reason For Leaving

Employer 2		Address
City		State
Zip
Supervisor Name		Supervisor Phone
Start Date		End Date
Position		Avg Hours Per Week
Reason For Leaving

Employer 3		Address
City		State
Zip
Supervisor Name		Supervisor Phone
Start Date		End Date
Position		Avg Hours Per Week
Reason For Leaving

Employer 4		Address
City		State
Zip
Supervisor Name		Supervisor Phone
Start Date		End Date
Position		Avg Hours Per Week
Reason For Leaving

Equal Employment Opportunity Questionnaire
What Racial/Ethnic Category Do You Consider Yourself
	American Indian or Alaskan Native - All persons having origins in any of the original of North American
	Asian or Pacific Islander - All persons having origins in any of the original people of East, Southeast Asia, the Pacific Islands or Indian subcontinent. This area includes for example China, Japan, The Philippines Island and Samoe.
	Black - Not of Hispanic Origin. All persons having origins in any of the Black racial groups.
	Hispanic - All persons of Mexican, Puerto Rican, Cuban, Central or South America or other Spanish culture or origin.

Vietnam Veteran

Did you serve active duty in the armed services (for a period of more than 180 days) between August 5, 1964 and May 7, 1975
Yes No

Disabled Veteran

Are you entitled to disability compensation under laws administered by the Veterans Administration or disability rates at 30% or more, or are you a person whose discharge or release from active duty was for a disability incurred or aggravated in the line of duty.
Yes No If yes list disability.

Handicapped

Do you (1) have a physical or mental impairment which substantially limits one or more major activities. (2) have a secure record of such impairment, (3) are regarded as having such impairment or (4) have experienced difficulty, retaining or advancement in employment because of your handicap? Yes No

Our company is committed to respectful and equal treatment for all employees. This commitment includes non-discrimination towards applicants and employees on the grounds of race, color, creed, religion, age, sex, disability, national origin, ancestry, sexual orientation, marital status or with regard to public assistance, or union or non-union status. This prevails throughout the employment relationship, including, but is not limited to recruitment, selection, training, transfer, compensation, promotions, demotions, layoff and termination.

3 Work Related References (no family members, relative or personal friends)

Most Recent Supervisor Name		Reference 1
Company		Company
Telephone		Telephone
Position You Held		How Do You Know This Person?
May We Contact This Person?

Reference 2		Reference 3
Company		Company
Telephone		Telephone
How Do You Know This Person?		How Do You Know This Person?

Applicant Release, Please Read

I authorize the investigation of my background including all information contained in this application and information provided in the interview. I understand that misrepresentation or omission of information in connection with applicant and interview will be sufficient cause, in and of itself for rejection or dismissed whenever discovered. I understand and agree that any offer of employment is contingent upon satisfactory completion of Moore’s Special Nurses pre-employment investigation on which includes but is not limited to health assessment, criminal history check educational and work verification, reference checks, consumer report and any investigation required by local, state or federal laws. I understand that if I am hired by Moore’s Special Nurses, my employment will be for an indefinite period of time and will be “at will” which means either Moore’s Special Nurses or I may terminate the employment relationship at anytime and for any reason or no reason.

I further understand that if hired, my at-will employment status may only be changed in written contract signed by management of Moore’s Special Nurses and that no representative of Moore’s Special Nurses has the authority t make oral promise to me concerning my employment. Finally, I also understand that Moore’s Special Nurses may adapt from time to time, policies or handbooks dealing with benefits and other terms or conditions of employment. These policies or handbooks do not constitute a contract of employment between Moore’s Special Nurses and me. Moore’s Special Nurses reserves the right to change or discontinue these policies and/or handbooks at any time with or without notice to me.

Moore’s Special Nurses strives to provide a safe healthy and productive work environment and supports a smoke free alcohol-free work environment.

Press the "Submit" button once.

Incomplete Applications Will Not Be Processed.