LPN Application Form

* = Required Information

Position Applied for:

LPN

CNA

Other

Date you can start:*

Other

Personal Information

Last Name*

First Name*

M.I.*

Social Security No.

Home Phone

Address

Cell Phone

City

State

ZIP

Best time to call:

Work Phone

Have you ever used a different name?

Yes

Please list

General Data

Are you eligible for employment in the United States?

Have you ever been convicted of a crime?

Yes

Please Describe

Personal References

List the name, address, and phone of two persons that are not related to you and are not previous employers:

Name:

Years Known:

Address:

Phone:

Name:

Years Known:

Address:

Phone:

Name of Applicant:

License/ Certification Information

Type:

Number:

Expiration:

Type:

Number:

Expiration:

Type:

Number:

Expiration:

Have any of your professional licenses ever been subject to disciplinary action by any state board or body, such as by reprimand, suspension, revocation, consent order, restriction, voluntary surrender or fines?

Yes

Please give detailed description:

Are you aware of any pending investigations against any of your professional licenses?

Yes

Please give detailed description:

Have you ever had a nursing license in any other state?

Yes

Please list:

Do you have any restrictions which will interfere with your ability t operform the essential duties of the position for which you have applied?

Yes

Please describe:

Please list any special skills, training, and/or certifications that may additionally qualify you for the position which you are applying for:

Work Availability

Please indicate all that you are interested in:

4-5 days

3-4 days

1-2 days

Other

Please indicate shift(s):

7-3

3-11

11-7

Weekends

Please indicate setting(s) which you prefer:

Hospital

Nursing Home

Other

Who should be contacted in case of an emergency while you are working:

Name

Relation

Phone 1

Phone 2

Address

Name of Applicant:

Employment History

Employer

Phone

Address

City

State

Zip

Start Date:

End Date:

Supervisor:

Position held:

Describe duties

Reason for leaving:

Hour pay rate: $

May we contact:

Yes

Why?

Employer

Phone

Address

City

State

Zip

Start Date:

End Date:

Supervisor:

Position held:

Describe duties

Reason for leaving:

Hour pay rate: $

May we contact:

Yes

Why?

Employer

Phone

Address

City

State

Zip

Start Date:

End Date:

Supervisor:

Position held:

Describe duties

Reason for leaving:

Hour pay rate: $

May we contact:

Yes

Why?

Authorization Agreement for Automatic Deposit(ACH Credits)

I hereby, authorize Stallion Group (hereinafter called Company) to initiate debit entries and adjustments for any credit entries in error to my Checking Account/Savings Account indicated below and the depository named velow (hereinafter called Depository) to credit and/or debit the same to such account.

This authority is to remain in full force and effect until the Company has received written notification from me of its termination in such time and in such manner as to afford the Company and the Depository a reasonable opportunity in act on it.

Name:

Social Security #:

Date:

Name:

City:

Branch:

State:

Zip Code:

Transit/ABA #:

Account #: