Complete Online Application
Required fields are in Blue     
Catagory Years Catagory Years
M/S Psych
Telemetry ER
Critical Care OR
CCU Maternal Child
CVICU/Openheart OB
MICU Nursery
SICU L&D
NICU Dialysis
PICU Long Term Care
PACU PEDES
Additional Experience: Description:
Additional Experience: Description:
 
Education
Institution: Address:
City: Zip Code:
State: Highest
Degree(s):
End Date:
Record Of Employment
Give present employer first
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 (a year or more)
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:  State  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:  State  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:    Still Employed:
Phone: - - Staffed position? Yes No
Fax: - - If not - With what Agency?
Reason for Leaving: Phone: - -
   
2nd Employer
Facility Name: Title:    Unit:
Address: Hours per Week:   Travel assignment? Yes No
City: State: Zip: Employed From:
Supervisor: Employed To:   Still Employed:
Phone: - - Staffed position? Yes No
Fax: - - If not - With what Agency?
Reason for Leaving: Phone: - -
   
3rd Employer
Facility Name: Title:    Unit:
Address: Hours per Week:   Travel assignment? Yes No
City: State: Zip: Employed From:
Supervisor: Employed To:   Still Employed:
Phone: - - Staffed position? Yes No
Fax: - - If not - With what Agency?
Reason for Leaving: Phone: - -
   
4th Employer
Facility Name: Title:   Unit:
Address: Hours per Week:   Travel assignment? Yes No
City: State: Zip: Employed From:
Supervisor: Employed To:   Still Employed:
Phone: - - Staffed position? Yes No
Fax: - - If not - With what Agency?
Reason for Leaving: Phone: - -
   
   
Last Name:
First:
Middle:
Title: Specialty Unit:
Social Security Number: - -
Home Address:
City: Zip:
Mailing Address,
if different from home address :
City: Zip:
Home Phone: - -
Work Phone: - - Ext:
Other Phone: - -
Cell Phone: - -
Email:
What position are you applying for? Per Diem Travel Other:
If Travel, select your desired location:
Or enter as many locations as you wish:
When can you start? ASAP
Which shift? Days Evenings Nights Flexible
Insurance -  
Malpractice Company:
Policy #:
Expiration Date:
Criminal Record?  
Has your license or ceritification ever been investigated or suspended? Yes No
Have you ever been convicted of a crime
other than a minor traffic violation?:		 Yes No
Has any malpractice claim or suit ever been
brought against you?		 Yes No
If any of above is "yes", please give explanation indicating dates, circumstances and final outcome
In Case Of Emergency Notify -  
Name / Relationship:
Phone: - -
Adddress:
Licensure -  
License Number and State:
Expiration Date:
Do you have multi state license privilege? Yes No
Other states you have licensure to travel:  
Cardiac: 1 2 3 Pediatrics: 1 2 3 Neurology 1 2 3
ACLS Calculation of Pedi Dosages Neuro Sign
Perform 12 Lead EKG PICU Seizure Precautions
Interpret Arrhythmias Starting IV Therapy Assist With LP
Defib/Cardioversion Scalp Veins ICP Monitoring
Telemetry Apnea Monitor Crutchfield Tongs
Pacemaker-Permanent Cardiac Monitor Halo Tractions
Pacemaker-Temporary CPR Infant/Child Stryker Frame
Rotating Tourniquets Prep Of Emergency Drugs Seizures
Peds Cardiac Surgery Recovery Trach Care And Suctioning VP Shunt
CPV Readings Assist With LP Spinal Cord Injury
A-Lines/Setup/Draw Gases Oxygen Neuro Rauma
Swan Ganz Pcwp Reading Croup Tent Prepost Neuro Surgery
Intra Aortic Balloon Pump Ventilators Overdose
Cardiac Output Bone Marrow Biopsy CVA
Mast Suit Asthma Safety Devices
  Broncho Pulmonary Dysplasia        
Care of Patient With: 1 2 3 Cardiac Surgery Maternal Child: 1 2 3
Airways Maintenance CHF Magnesium Sulfate RX
Aneurysm Cystic Fibrosis Labor Suppressants
Acute MI Diabetes Mellitus Oxtocin Induction/ Augment
Pre/Post Cardiac Cath Epiglottitis Assist With Vag Del
CHF Failure To Thrive Forceps Vag Del
Cardio/Hypovlemic Shock Leukemia Circ For C-Section
Pre/Post CABG Surgery Meningitis Scrub For C-Section
  Near Drowning Internal Monitor
Drugs: 1 2 3 Overdose Poison Ingestion Intrauterine Pres. Cath.
ASA Pda Ligation Fetal Scalp Blood Sample
Adenosine RDS Labor Assessment
Atropine Reye's Syndrome Vag Exams
Bretylium Sickle Cell Disease Fetoscope Doppler
Ca+Chloride Spina Bifida Identify FHR Patterns
Digoxin Tracheoesphageal Fistula Pregnancy Induced Hypertension
Dobutrex   Preclampsia
Dopamine Genitourinary: 1 2 3 Abruptio Placenta
Epinephrine Foley Catheter Insertion Malpresentations
Inderal G.U. Irrigations Premature Labor
Isuprel Ileostomy Diabetes Mellitus
Lidocaine Nephrostomy Tube Infectious Disease
Nipride Suprapubic Tube Sickle Cell Disease
NTG Shunts & Fistulas RH Incompatibilities
Pronestyl Renal Transplant Fundus Consistency
Quinidine   Lochia
        Dressing / Drains: 1 2 3 Bladder Distention
Drugs: 1 2 3 Change Episiotomy/ Incision For C-Section
Decadron Wound Irrigation
Dilantin Sterile Dressing Gynecology: 1 2 3
Mag. Sulfate Transparent Occlusive Endometriosis
Phenobarbital Hemovac GYN Exam/Pap
Valium Jackson Pratt Self Breast Exam
                Hysterectomy
Respiratory: 1 2 3 Operating Room: 1 2 3 Psychiatric: 1 2 3
Lung Assessment Out Patient Surgery Admission of Patient
Oral Pharyngeal Suction GU And Renal Adolescent
Cuffed Tracheotomy GYN Patient in Seclusion
Oxygen Masks/ Cannulas OB Suicide Precautions
ET Intubation/ Extubation Plastics ECT
Use Complications of Peep Ortho 4 Point Restraints
Use Complications of CPAP Neuro D.T.S.
Use Complications of IMV Cardio/Vascular Schizophrenia
Ventilator Weaning Open Heart Anorexia
ABG Interpretation ENT Tubes
Arterial Blood Stick Ophthalmology Obsessive/Compulsive
Postural Drainage/ Percussion GI Substance Abuse
Chest Tubes Scopes Aggressive/ Combative
Obstructed Airway Laser Manic/Depressive
Near Drowning Transplants Group
COPD Harvesting Medications
ARDS Thoracic        
Pre/Post Thoracic Surgery         Vascular: 1 2 3
Pulmonary Emboli         Peripheral Pulses
Asthma Orthopedic: 1 2 3 Dehydration
Apnea Monitor Total Knee Replacement Fluid Overload
Incentive Spirometry Total Hip Replacement Ultrasonic Doppler
        Arthroscopy/Arthrotomy Starting IV’s
Newborn Care: 1 2 3 Amputation Heparin Locks
Calc. Of Neonatal Dosages Trauma TPN/ Hyperal
Neonatal Level II Buck's Traction Normal Serum Lab Values
Neonatal Level III Crutch Walking Obtaining Venous Blood
Draw Blood From U Line K Wires Shock
Suction With Catheter Cast Care Infusion Pumps
Cord And Circ Care Spika Cast Hickman/ Broviac Caths
Phototherapy Circo Electric Bed Hemodialysis
NG Feedings Tens Peritoneal Dialysis
Admin Blood And Blood Products                
        Immediate Neonatal Care: 1 2 3 Other: 1 2 3
Gastointestinel: 1 2 3 Assign Apgar Scores Oncology
NG Tube Suction Chemotherapy
Gastrostomy Tube Eye Prophylaxis Bone Marrow Biopsy
Jejumostomy Tube Collect Cord Blood Diabetic Teaching
T Tube         Isolation Techniques
GI Bleed Home Health: 1 2 3 Liver Transplant
Miller-Abbott Cantor Medicare Documentation Aids
Colostomy Care Case Management Alzheimer's
Dehiscense Ventilators Pre/Post Eye Surgery
                       
Use Of Equipment: 1 2 3                
Cardiac Monitors                
Oxyhood                
Apnea Monitors