The Nurse Network - Contact Information

Contact Information www.thenursenetwork.com

Required fields are indicated by "•"
• First Name:
Middle Name:
• Last Name:
Social Security #:
• Street Address/ P.O. Box:
• City:
• State/Country:
• Zip:
• Home Phone:
Cell Phone:
Fax:
Pager:
E-mail Address:
Emergency Contact Name:
Emergency Contact Address:
Emergency Contact Phone:
Driver's License State:
Driver's License Number:
Driver's License Expires:	(mm/dd/yyyy)
• Are you legally authorized to work in the United States?	Yes No
Who can we thank for your referral?
• Have you ever applied to or been employed by The Nurse Network?	Yes No
• Have you ever been convicted of any misdemeanor or felony within the last 7 years?	Yes No
• Check As Appropriate: (Certification)	Foreign RN Foreign Supervisor Clerk LPN RN RNS RNSW CNA PT OT RT ADMIN MD PA STUDENT LPN STUDENT RN Puerto Rican Recruit Director of Nursing Asst Director of Nursing Admissions Director Nurse Practitioner Nurse Educator P.T.A. O.T.A. CMA US Tech Office Personnel SLP Surgical Tech
Type of Employment Desired:	Travel (13-26 weeks) Per Diem Direct Placement Fast Response (4 week only)
Type of Shifts:	8 Hour Shifts 12 Hour Shifts 10 Hour Shifts Other
Shift Preference:	DAY NOC EVE


• Please select, from the following, the skill/unit in which you have one year experience in the past 24 months as primary care:
Hospital
GERI
ACLS
CARDIAC
CCU
CVICU
DIAL
ECS
ER
ICU
L&D
M/S
NEURO ICU
IV CERT.
NICU
NICU2
NICU3
NURSERY
NURSING HOME
OB
ONCO
ON CALL
OR
ORTHO
PACU
PALS
PCU/MCU
PEDS
PICU
POST PARTUM
PSYCH
TELE
TRANS
VENT/TREACH
HomeCare
CORRECTION
ReHab
Supervisor Exp
Marathon Health Care
RESPITORY
Self Booked Shift
Northbridge
English
NCLEX
Passport
MDS coordinator
educator
APRN
Strike
GENESIS
Infection Control
Director of Nurses
Administrator
Assistant Director of Nurses
Public Health Nurse
Cath Lab
Case Manager
New Grad. / No Specialty
Social Worker

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SEXUAL/RACIAL HARASSMENT POLICY It is the policy of The Nurse Network that employees have the right to work in an environment free of any form of sexual or racial harassment. If you feel that you have been sexually or racially harassed, please call your The Nurse Network Representative immediately. In the event that you are unable to contact them, please feel free to contact our corporate office. Any associate who advises us of a possible harassment situation will not suffer repercussions due to the voicing of the complaint.

By clicking "Continue" I agree that: I have read and fully understand the questions asked in this application and that all answers given by me are true, accurate, and complete. I also understand that the omission, concealment, or misrepresentation of any fact on this application or during any interview, may be grounds to refuse assignments. I give the Company permission to use any information in this application to enable it and its agents to verify the information contained in this application, and I authorize present and former employers, educational institution I have attended, credit agencies, all references, and any other persons to answer all questions asked by the Company, The Nurse Network may conduct a criminal background investigation and that my involvement with the Company may be contingent upon the results of such investigation. I release the Company, its agents, and all affiliated entities, as well as any person or institutions that provides the Company with any information about me, from any and all liability whatsoever resulting from any such investigation or the disclosure of such information. In consideration of being offered contract assignments by The Nurse Network, I agree to abide by all Company rules and regulations, which I understand are subject to change by the Company at any time for any reason without prior notice. I further understand that no communication, whether oral or written, by any representative of the Company, at any time, can constitute a contract of employment. No representative or agent of the company other than the Director of Human Resources by either written or mutually signed agreement, has the authority to enter into any agreement for employment for any specific period of time or to make any agreement contrary to the foregoing. I am willing to submit to a physical examination, including the analysis for the detection of the use of unlawful drugs or substances in accordance with applicable laws. I agree, in consideration of your offering contract assignments, that I will not seek or accept employment, either directly or indirectly in any capacity from any client of The Nurse Network to whom I have been assigned, for at least 90 working days after the last day of that assignment. I also agree that I will not solicit these clients on my behalf nor on behalf of any future employer(s). I further understand that I cannot be paid until I present a time slip signed by both the client and me to The Nurse Network office. I understand that The Nurse Network does not provide auto insurance coverage for me and that I am not to transport patients in my automobile, nor am I to drive patients in the patient's automobile without written consent from The Nurse Network.