Nurse Qualification Form

Please complete the form below and we will contact you shortly.

*First Name:  
*Last Name:  
Middle Initial:  
Home Address:  
City:  
State/Province:  
Zip:  
Country:  
Current Address (if different from home):  
*Email:  
*Home Phone: - -
country code - area code - phone number		  
Current Phone: - -
country code - area code - phone number 		 
Work Phone: - - Ext:
country code - area code - phone number 		 
Cell Phone: - -
country code - area code - phone number 		 
Fax Number: - -
country code - area code - phone number 		 
     
In case of emergency, contact:  
Relationship:  
Phone:  
     
Are you a registered nurse?
yes no     Degree: 		 
Have you ever been convicted of a crime?
yes no		  
Do you have a U.S. Social Security Number?
yes no     SSN: 		 
     
Have you taken NCLEX?
yes no      		 
Which State?  
Did you pass?
yes no      Date: 		 
NCLEX License #:  
Expiration Date:  
Did you review for NCLEX exam?
yes no      		 
Do you have any other state licenses?
yes no      Which? 		 
     
Have you taken CGFNS?
yes no      		 
Score:      Date:  
Do you have a CGFNS certificate?
yes no      CGFNS ID#: 		 
     
Have you ever taken the TOEFL?
yes no      		 
Did you pass the exam?
yes no		  
Score:      Date:  
     
Have you ever taken the TSE?
yes no      		 
Did you pass the exam?
yes no		  
Score:      Date:  
     
Have you ever taken the IELTS?
yes no      		 
Did you pass the exam?
yes no		  
Score:      Date:  
Spoken Score:    
Do you have a IELTS certificate?
yes no      IELTS Certificate #: 		 
   
Are you currently in United States?
yes no      		 
If yes, what is your current immigration status??
  
   
How did you hear about us?
google.com
yahoo.com
Other Search Engine
Internet/Web Ad
Direct Mail
Magazine/Journal 
      which one?
Newspaper
      which one? city:
Job Fair
      which one? city:
Referral
     who? country: 		 
   
Education and Training:  
Education Name and Address of School
High School
Month/Year Graduated:
Diploma/Degree:
College
Month/Year Graduated:
Diploma/Degree:
Graduate School
Month/Year Graduated:
Diploma/Degree:
Other School
(if applicable)
Month/Year Graduated:
Diploma/Degree:
 
   
Current Certifications:
 BLS ACLS PALS NRP TNCC CHEMO Other(s) 		 
   
 
Specialty Pimary Float
MEDICAL SURGICAL-Adult
Diabetic Unit   yrs:   yrs:
Gastrointestinal Unit   yrs:   yrs:
General Surgery   yrs:   yrs:
Genitourinary Unit   yrs:   yrs:
Geriatric Unit   yrs:   yrs:
Gynecology Unit   yrs:   yrs:
Hematology Unit   yrs:   yrs:
Hemodialysis Unit   yrs:   yrs:
Home Health   yrs:   yrs:
Hospice Unit   yrs:   yrs:
Renal Unit   yrs:   yrs:
Neurology Unit   yrs:   yrs:
Oncology Unit   yrs:   yrs:
Outpatient Clinic   yrs:   yrs:
Pulmonary Unit   yrs:   yrs:
Radiology Services   yrs:   yrs:
Rehabilitation Unit   yrs:   yrs:
Same Day Surgery Unit   yrs:   yrs:
Skilled Nursing Facility   yrs:   yrs:
Clinic   yrs:   yrs:
Other:   yrs:   yrs:
MEDICAL SURGICAL-PEDS
General Peds Unit   yrs:   yrs:
Home Health   yrs:   yrs:
Hospice Unit   yrs:   yrs:
Oncology Unit   yrs:   yrs:
Rehab Unit   yrs:   yrs:
Other:   yrs:   yrs:
PERINATAL
Antepartum Unit   yrs:   yrs:
Labor & Delivery   yrs:   yrs:
LDRP   yrs:   yrs:
High Risk Labor & Delivery   yrs:   yrs:
Mother Baby Unit   yrs:   yrs:
NICU Level II   yrs:   yrs:
NICU Level III   yrs:   yrs:
Fetal Monitoring   yrs:   yrs:
Newborn Healthcare   yrs:   yrs:
PERINATAL-cont.
Postpartum Unit   yrs:   yrs:
Other:   yrs:   yrs:
PERIOPERATIVE
Cardiovascular OR   yrs:   yrs:
General Surgery   yrs:   yrs:
Neurosurgical OR   yrs:   yrs:
Operating Room   yrs:   yrs:
Orthopedic OR   yrs:   yrs:
Same Day Surgery   yrs:   yrs:
Transplant OR   yrs:   yrs:
ENT/Ophthalmology OR   yrs:   yrs:
Bone Marrow Transplant OR   yrs:   yrs:
CRITICAL CARE-Adult
Burn ICU   yrs:   yrs:
Cardiac ICU   yrs:   yrs:
Cardiac Catheterization Lab   yrs:   yrs:
Emergency Room   yrs:   yrs:
Medical ICU   yrs:   yrs:
Neuro ICU   yrs:   yrs:
Neurosurgical ICU   yrs:   yrs:
Transplant ICU   yrs:   yrs:
Surgical ICU   yrs:   yrs:
Telementry/Stepdown   yrs:   yrs:
Post-Op Open Heart   yrs:   yrs:
CRITICAL CARE-Peds
Burn ICU Peds   yrs:   yrs:
Cardiac Catheterization Lab   yrs:   yrs:
Emergency Room Peds   yrs:   yrs:
Pediatric ICU   yrs:   yrs:
Pediatric - Transplant ICU   yrs:   yrs:
Pediatric Step-down Unit   yrs:   yrs:
PSYCHIATRY
Adolescent Psychiatric   yrs:   yrs:
Dual Diagnosis Unit   yrs:   yrs:
Adult   yrs:   yrs:
Pediatric Psychiatric Unit   yrs:   yrs:
Emergency Room   yrs:   yrs:
Correction Facility   yrs:   yrs:
 
   
Other Fields of Nursing:  
Clinic Nursing:
Area: Years of Experience:

Long Term Care: Years of Experience:

Other: Please Explain: