Complete Online Application
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
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: 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:
- -
Date of Birth:
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?
Have you ever been convicted of a crime?:
Yes No
If yes, state where:
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
ACLS
Calculation of Pedi Dosages
Perform 12 Lead EKG
PICU
Interpret Arrhythmias
Starting IV Therapy
Defib/Cardioversion
Scalp Veins
Telemetry
Apnea Monitor
Pacemaker-Permanent
Cardiac Monitor
Pacemaker-Temporary
CPR Infant/Child
Rotating Tourniquets
Prep Of Emergency Drugs
Peds Cardiac Surgery Recovery
Trach Care And Suctioning
CPV Readings
Assist With LP
A-Lines/Setup/Draw Gases
Oxygen
Swan Ganz Pcwp Reading
Croup Tent
Intra Aortic Balloon Pump
Ventilators
Cardiac Output
Bone Marrow Biopsy
Mast Suit
Asthma
Broncho Pulmonary Dysplasia
Care of Patient With:
1
2
3
Cardiac Surgery
Airways Maintenance
CHF
Aneurysm
Cystic Fibrosis
Acute MI
Diabetes Mellitus
Pre/Post Cardiac Cath
Epiglottitis
CHF
Failure To Thrive
Cardio/Hypovlemic Shock
Leukemia
Pre/Post CABG Surgery
Meningitis
Near Drowning
Drugs:
1
2
3
Overdose Poison Ingestion
ASA
Pda Ligation
Adenosine
RDS
Atropine
Reye's Syndrome
Bretylium
Sickle Cell Disease
Ca+Chloride
Spina Bifida
Digoxin
Tracheoesphageal Fistula
Dobutrex
Dopamine
Genitourinary:
1
2
3
Epinephrine
Foley Catheter Insertion
Inderal
G.U. Irrigations
Isuprel
Ileostomy
Lidocaine
Nephrostomy Tube
Nipride
Suprapubic Tube
NTG
Shunts & Fistulas
Pronestyl
Renal Transplant
Quinidine
Psychiatric:
1
2
3
Operating Room:
1
2
3
Admission of Patient
Out Patient Surgery
Adolescent
GU And Renal
Patient in Seclusion
GYN
Suicide Precautions
OB
ECT
Plastics
4 Point Restraints
Ortho
D.T.S.
Neuro
Schizophrenia
Cardio/Vascular
Anorexia
Open Heart
Tubes
ENT
Obsessive/Compulsive
Ophthalmology
Substance Abuse
GI
Aggressive/ Combative
Scopes
Manic/Depressive
Laser
Group
Transplants
Medications
Harvesting
Thoracic
Neurology:
1
2
3
Neuro Sign
Seizure Precautions
Orthopedic:
1
2
3
Assist With LP
Total Knee Replacement
ICP Monitoring
Total Hip Replacement
Crutchfield Tongs
Arthroscopy/Arthrotomy
Halo Tractions
Amputation
Stryker Frame
Trauma
Seizures
Buck's Traction
VP Shunt
Crutch Walking
Spinal Cord Injury
K Wires
Neuro Rauma
Cast Care
Prepost Neuro Surgery
Spika Cast
Overdose
Circo Electric Bed
CVA
Tens
Safety Devices
Drugs:
1
2
3
Dressing / Drains:
1
2
3
Decadron
Change
Dilantin
Wound Irrigation
Mag. Sulfate
Sterile Dressing
Phenobarbital
Transparent Occlusive
Valium
Hemovac
Jackson Pratt
Gynecology:
1
2
3
Other:
1
2
3
Endometriosis
Oncology
GYN Exam/Pap
Chemotherapy
Self Breast Exam
Bone Marrow Biopsy
Hysterectomy
Diabetic Teaching
Isolation Techniques
Home Health:
1
2
3
Liver Transplant
Medicare Documentation
Aids
Case Management
Alzheimer's
Ventilators
Pre/Post Eye Surgery
Maternal Child:
1
2
3
Gastointestinel:
1
2
3
Magnesium Sulfate RX
NG Tube
Labor Suppressants
Gastrostomy Tube
Oxtocin Induction/ Augment
Jejumostomy Tube
Assist With Vag Del
T Tube
Forceps Vag Del
GI Bleed
Circ For C-Section
Miller-Abbott Cantor
Scrub For C-Section
Colostomy Care
Internal Monitor
Dehiscense
Intrauterine Pres. Cath.
Fetal Scalp Blood Sample
Respiratory:
1
2
3
Labor Assessment
Lung Assessment
Vag Exams
Oral Pharyngeal Suction
Fetoscope Doppler
Cuffed Tracheotomy
Identify FHR Patterns
Oxygen Masks/ Cannulas
Pregnancy Induced Hypertension
ET Intubation/ Extubation
Preclampsia
Use Complications of Peep
Abruptio Placenta
Use Complications of CPAP
Malpresentations
Use Complications of IMV
Premature Labor
Ventilator Weaning
Diabetes Mellitus
ABG Interpretation
Infectious Disease
Arterial Blood Stick
Sickle Cell Disease
Postural Drainage/ Percussion
RH Incompatibilities
Chest Tubes
Fundus Consistency
Obstructed Airway
Lochia
Near Drowning
Bladder Distention
COPD
Episiotomy/ Incision For C-Section
ARDS
Pre/Post Thoracic Surgery
Immediate Neonatal Care:
1
2
3
Pulmonary Emboli
Assign Apgar Scores
Asthma
Suction
Apnea Monitor
Eye Prophylaxis
Incentive Spirometry
Collect Cord Blood
Newborn Care:
1
2
3
Vascular:
1
2
3
Calc. Of Neonatal Dosages
Peripheral Pulses
Neonatal Level II
Dehydration
Neonatal Level III
Fluid Overload
Draw Blood From U Line
Ultrasonic Doppler
Suction With Catheter
Starting IV’s
Cord And Circ Care
Heparin Locks
Phototherapy
TPN/ Hyperal
NG Feedings
Normal Serum Lab Values
Admin Blood And Blood Products
Obtaining Venous Blood
Shock
Use Of Equipment:
1
2
3
Infusion Pumps
Cardiac Monitors
Hickman/ Broviac Caths
Oxyhood
Hemodialysis
Apnea Monitors
Peritoneal Dialysis