LPN APPLICATION

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PRECISION HEALTHCARE MS STAFFINGLPN APPLICATION

Introduction and Checklist 

Instructions: Please view the application checklist, upload the required documents, and fill out the form below.

application checklist

upload documents

Thank you!

We have received your submission.

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Nurse Name

Phone Number

Email

LPN Contractor Service Application

Email

Orientation

TB Date

Full Name

Tax ID/SSN

Address: City, State, and Zip Code

Cell Phone Number

Phone Number

Date of Birth

Are you a U.S. Citizen?

Yes

No

Have you ever been a contractor with us?

Yes

No

If yes, what dates?

Which state(s)?

Professional Information

State(s) where licensed

License #

CPR Certification?

Yes

No

Expiration Date

Other Medical Certification

Education

High School or GED?

Date Graduated

Availability

Shift preference

12 hours?

Yes

No

Employment History

Company Name

Phone Number

Address: City, State, and Zip Code

Job Title

Supervisor

Reason for leaving

Dates From/To

Company Name

Phone Number

Address: City, State, and Zip Code

Job Title

Supervisor

Reason for leaving

Dates From/To

Company Name

Phone Number

Address: City, State, and Zip Code

Job Title

Supervisor

Reason for leaving

Dates From/To

Date

The information on this application is accurate and subject to verification. I understand that any misleading or incorrect statements may render this application void.

Contractor's Statement of Health Status

Name

Date

Social Security Number

Date of birth

Position

Have you ever had, or do you now have any of the following:

. Frequent or Severe Headaches, Head Injury or Stroke

Option 2

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