Nurse Application
PLEASE PRINT ALL INFORMATION EXCEPT SIGNATURE
APPLICANTS MAY BE TESTED FOR ILLEGAL DRUGS
Name: _______________________
Last
Present Address:
_____________ ________________
First Middle
Number Street
Contact information:
___________________________
Phone
City State
____________________________________
E-mail
zip
Employment Desired: Full time only
Salary Desired: $______________/hr
Days and hours per week available:
Part-time only Either
______ _______ _______ _______ ________
Mon Tue Wed Thur
When would you be available to start?
Fri

EDUCATION AND OTHER INFORMATION
TYPE OF NAME OF
SCHOOL SCHOOL
LOCATION # MAJOR/
(ADDRESS) YEARS DEGREE
_____________I___________________I__________________I____________I_________
High School
_____________I___________________I__________________I_____________I_________
College
_____________I____________________I__________________I____________I_________
Business or Trade
School
_____________I_____________________I__________________I_____________I_______
Professional
School
_____________I_____________________I__________________I_____________I_______
Current licenses you hold (State and exp. date)
MILITARY
Have you ever been in the armed forces?
Are you in the National Guard?
Specialty Date Entered
Yes
Yes
No
No
Discharge Date
_________________I___________________________I______________________________

Have you ever been convicted of a crime? Yes
If yes please explain –
Do you have a driver’s license? Yes
Have you used an Electronic medical record? Yes
If yes which ones?
WPM_______ Typing Yes
Personal computers:
PC
Macintosh
Yes
Yes
No
No
No
No
No
No
Please list two references other than relatives or previous employers.
Name: Position:
Company:
Address:
____________________________________________________________________________________
Telephone:
Name: Position:
Company:
Address:
____________________________________________________________________________________
Telephone:

WORK EXPERIENCES
Please list your work experiences for the last 5 years beginning with your most recent job. If you were self employed, give company’s name. Attach additional sheets if necessary.
JOB ONE
Name of Last Employment
Name of Employer: Supervisor Dates Salary
________________________I__________________I__________________I____________
________________________I__________________I From: _________Start:______
Complete Address:
To: __________Final:_____
________________________I__________________I_______________________________
Phone Number: Your Last Job Title:
___________________________________________I_______________________________
Reason for Leaving (be specific):
List the jobs you held, duties preformed, skills used or learned, advancements or promotions while at this company.

JOB TWO
Name of Last Employment
Name of Employer: Supervisor Dates Salary
________________________I__________________I__________________I____________
________________________I__________________I From: _________Start: _____
Complete Address:
To: __________Final:_____
__________________________________________I_______________________________
Phone Number: Your Last Job Title:
___________________________________________I_______________________________
Reason for Leaving (be specific):
List the jobs you held, duties preformed, skills used or learned, advancements or promotions while at this company.

JOB THREE
Name of Last Employment
Name of Employer: Supervisor Dates Salary
________________________I__________________I__________________I____________
________________________I__________________I From: _________Start: _____
Complete Address:
To: __________Final:_____
________________________I__________________I_______________________________
Phone Number: Your Last Job Title:
___________________________________________I_______________________________
Reason for Leaving (be specific):
List the jobs you held, duties preformed, skills used or learned, advancements or promotions while at this company.
May we contact your present employer? Yes No

Nursing Skills – Please rate on scale of 1-5
1(unable) 3(Proficient) 5(skilled)
__________________________________________________________________________
Injections
Start IV’s
Draw Blood
In/out bladder
Catheterization
Call in Rx’s
Assist in minor
Surgeries
Assist in PAP/
Pelvic Exams
Call patients with results or advice
What is the one thing your enjoy most about Nursing?
An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the space below to add any additional information necessary to describe your full qualifications for the nursing job for which you are applying.

APPLICATION FORM WAIVER
In exchange for the consideration of my job application by Direct Primary Care of
Northwest Arkansas (hereinafter called “The Company”), I agree that:
Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements and the like as they may exist from time to time, or other
Company practices shall serve to create an actual or implied contract of employment, or to confer the right to remain an employee of “The company”, or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the managers of Integritas LLC. Both the undersigned The
Company may end the employment relationship at any time, in writing and with 2 weeks notice. If employed I understand that The Company may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits.
I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give The Company permission to contact schools, previous employers (unless otherwise indicated), references and others and hereby release The Company from any liability as a result of such contact.
I also understand that (1) The Company has a drug and alcohol policy that provides for pre-employment testing as well as testing after employment.
(2) Consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy.
I further understand that my employment with The Company shall be probationary for a period of (60) days, and further that at any time during the probationary period or thereafter, my employment relation with The Company is terminable at will for any reason or any party.
Signature of Applicant Date:
________________________________________________________________________________________________
This company is an equal opportunity employer, thank you for completing this application form and your interest in our practice.