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Catagory
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PACU
Additional Experience:
Description:
Additional Experience:
Description:
Education
Institution:
Address:
City:
Zip Code:
State:
Highest
Degree(s):
End Date:
Record Of Employment
Nursing Skills Checklist
What is Your Level Of Ability in The Areas Listed Below?
1- No Experience
2- Some Experience (6-12 Months)
3- Fully Experienced (More than 12 months)
Confirmation and Authorization:The statements made in the skills checklist above are true to the best of my knowledge. I authorize White Glove to validate the information I have provided and to get in touch with my previous employers concerning my ability and employment record. I understand that any falsification will be the basis for ineligibility of employment.
 By checking this box and typing my name below, I agree to the Confirmation and Authorization above.
Full Name:

Specialty Experience
 Please print name and address of your previous employer below:
Facility:
Address:
City:
 Zip:
Phone:
 - -
Fax:
Attention To:
Please print your information
Name:
Social Security #:
I was employed from:
 TO Still Employed
Clinical Area/Unit
Kindly select one:
 RN LPN CNA NT ORT OTHER
Other:
For employer's use:
Dear Employer, The following applicant has applied for employement
with White Glove Agency. Kindly provide the requested information to
the best of your ability. The furnished reference information will be held
in strict confidence.
Please provide Previous employer information
Facility:
Address:
City:
 Zip:
Phone:
 - -
Fax:
Attention To:
Please print your information
Name:
Social Security #:
I was employed from:
 TO Still Employed
Clinical Area/Unit
Kindly select one:
 RN LPN CNA NT ORT OTHER
Other:
For employer's use:
Dear Employer, The following applicant has applied for employement
with White Glove Agency. Kindly provide the requested information to
the best of your ability. The furnished reference information will be held
in strict confidence.
Additional comments:
If no longer employed, reason for leaving:
Would you consider applicant for rehire?
If not, please explain: ................................................................................................................................................................................................
Signature:......................................................................................................................................................................................Date:
Title:...............................................................................................................................................................................................Facility:
Employer Reference Form
Employer Reference Form
I certify that all the information in the application provided is true to the best of my knowledge. I understand that my present and prior employers, persons, agencies and organizations may be contacted to obtain verification of information provided and may be asked to furnish details related to my employment or affiliation. I understand that misrepresentation or omission of facts may be cause for cancellation of this application, or dismissal from employment upon discovery.

I understand HIPPA regulations and the New York State regulations regarding HIV confidentiality. I agree to comply with the related White Glove policies and will hold all protected patient and health care organization information as confidential.

I authorize White Glove and any third party payment contracted to obtain my criminal background information and public records and to investigate any personal information on me necessary to arrive at an employment decision
.
By checking this box and typing my name below, I agree to the above.
Full Name:

Additional comments:
If no longer employed, reason for leaving:
Would you consider applicant for rehire?
If not, please explain: ................................................................................................................................................................................................
Signature:......................................................................................................................................................................................Date:
Title:...............................................................................................................................................................................................Facility:
Kindly complete the required fields in the following two reference forms.
Please enter accurate addresses and phone numbers, so that we can
successfully forward it to your employer.
Please Evaluate
Outstanding
Good
Fair
Poor
Knowledge of critical care standards:
Knowledge of med/surg standards:
Clinical skill competency:
Patient assesment ability:
Care planning and implementation:
Ability to work independantly:
Attendance and reliability:
Please Evaluate
Outstanding
Good
Fair
Poor
Knowledge of critical care standards:
Knowledge of med/surg standards:
Clinical skill competency:
Patient assesment ability:
Care planning and implementation:
Ability to work independantly:
Attendance and reliability:
1st Employer
Facility Name:
Title: Unit:
Address:
Hours per Week: Travel assignment? Yes No
City: State: Zip:
Employed From:
Supervisor:
Employed To: