Friends Who Care Health and Managed Care Services

	Friends Who Care
	RN/LPN EMPLOYMENT APPLICATION
	Use "TAB" key to move to each field. This will insure no information is missed.

Name:	SS#: Date:
Address:	Email:
City:	State: Zip:
Phone:	Drivers License #: State:
Position Desired:

EDUCATION	NAME/ADDRESS	MAJOR	FROM/TO	GRADUATE	DEGREE
High School:

College:

College:

Graduate School:

Additional Education:

License, Registration, Certificates:

Are you a student?

Yes No

How soon are you available for employment?

Are you 18 years or older?

Yes No

Salary requested:

Are you under a physician's care?

Yes No

Method of transportation:

Do you have any physical, mental or medical impairments or illnesses which may interfere with your ability to work the position which you applied for? If yes, explain below.

Yes No

Do you own a car?

Year/Make
Auto Insurance Company

Have you ever received Worker's Compensation? If yes, explain below.

Yes No

Yes No

Have you ever been convicted of a crime? If yes, explain below.

Yes No

Have you ever been employed under a different name? If yes, what?

Yes No

Are you available for positions other than for what you have applied?	Yes No
Are you available for weekends?	Yes No

Please list the hours which you will be available for work:

List any volunteer experience, skills, hobbies, interests:

List any duties you are unwilling/unable to perform:

List 3 character references, not related to you:

NAME	ADDRESS	PHONE	TITLE

Please list previously held positions. Include present employment if you are now employed. Begin with you most recent position.

EMPLOYER:

ADDRESS:

PHONE: TITLE:

TYPE OF BUSINESS: SALARY:

SUPERVISOR:

DATES OF EMPLOYMENT: From To

DUTIES:

REASON FOR LEAVING:

********************************************************************************

EMPLOYER:

ADDRESS:

PHONE: TITLE:

TYPE OF BUSINESS: SALARY:

SUPERVISOR:

DATES OF EMPLOYMENT: From To

DUTIES:

REASON FOR LEAVING:

*******************************************************************************

EMPLOYER:

ADDRESS:

PHONE: TITLE:

TYPE OF BUSINESS: SALARY:

SUPERVISOR:

DATES OF EMPLOYMENT: From To

DUTIES:

REASON FOR LEAVING:

This is a good time to print the application you have completed.

Then proceed and submit.

I certify that the statements on this document are true to the best of my knowledge. I realize that all the information furnished by me is important and that Friends Who Care will rely on this information in engaging me and continuing my employment. I also realize that this information may be verified, and any misrepresentation of facts may constitute cause for dismissal. In this connection I authorize all previous employers to cooperate with this agency and to release on a confidential basis any information they may have concerning me. I agree to abide by all agency rules and regulations.

fwc.berkley@yahoo.com Phone: 248-542-2424 Fax: 248-542-5621