Application form

RN-MEDICINE UNIT

PRN

Hours

12 Hour Shifts, Days/Nights/Weekends/Holidays

Previous Experience Required

Minimum of 1 year FT experience as a RN, preferred. Must be current with CPR.

Specialized or Technical Education Required

Must be a graduate of an accredited school of nursing, and be currently licensed by the State Board of Nursing. Membership in a professional organization is encouraged.

 Manual or Physical Skill Required

 Physical Effort Required

Must possess good physical health. Required to stand for long periods of time. Lifting and transporting of patients is required. Motor coordination and manual dexterity are necessary. Strength: Medium; Push: Occasionally; Pull: Occasionally; Carry: Occasionally; Lift: Occasionally; Sit: Occasionally; Stand: Frequently; Walk: Frequently

6.10.20-1

Personal Information

*All below fields are required.

Referral Information

*All below fields are required.

Placement Information

*All below fields are required.

Education

High School

*All below fields are required.

College

Graduate School

Vocational School/ Other

Certifications / Licenses

License 1

License 2

License 3

License 4

Skills & Qualifications

Employment History

Current Employer

Previous Employer 1

Previous Employer 2

References

*All below fields are required.

Reference 1

Reference 2

Reference 3

Applicants Statement

*All below fields are required.
  1. I verify that all information on my application, resumes, and exhibits submitted to Hood Memorial Hospital are true, correct, and complete and any false or misleading information furnished by me regarding my application will be sufficient cause for rejection of application or immediate dismissal if employed by Hood Memorial Hospital. 
  2. I verify that my application is not a job offer or a contract for employment.  If hired, I understand that any employment will be “at will” and for an indefinite time period.  I understand that I may resign or be terminated by the facility at any time without notice or requirement for cause. 
  3. I verify that I authorize persons, schools, organizations, my current employer and previous employers (unless otherwise noted) named in the application and accompanying resume to provide any relevant information that may be required to arrive at an employment decision. 
  4. I verify that employment may be subject to completion of preemployment procedures including, but not limited to, employment /personal references, background investigation, criminal records check, driving record verification (if applicable) and licensure /registration/ certification verification (if applicable).
  5. I understand that during my employment, if hired, I will report to my immediate supervisors any drug-related criminal conviction within five days of the conviction. 
  6. I understand that following an offer of employment, I may be required to undergo a health assessment.  This examination may include, but is not limited to, screening for infections, diseases, alcohol, and drugs.  Failure to undergo and/or pass the health assessment will result in disqualification from employment.  Failure to truthfully answer inquiries about previous medical conditions may result in my forfeiture of Worker’s Compensation benefits under R.S.23:1208.1.
  7. If accepted for employment, I hereby agree to abide by the rules, policies, procedures, and Customer Service standards of Hood Memorial Hospital. 
  8. I understand, if hired, I will be on a three-month initial evaluation period (unless otherwise defined) during which time I may be discharged without recourse.
  9. If hired, I understand that my hours of employment and work schedule may be changed at the discretion of Hood Memorial Hospital.

My typed name shall have the same force and affect as my written signature.

Note: Review the entire form to be sure no questions have been omitted if required.
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