Complete Online Application
Required fields are in Blue      
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:  
Specialty Experience
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
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: - -
   
   
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.
Employer Reference Form
  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. Kindly provide the requested information to
the best of your ability. The furnished reference information will be held
in strict confidence.
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:
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
  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. Kindly provide the requested information to
the best of your ability. The furnished reference information will be held
in strict confidence.
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:
Additional comments:
If no longer employed, reason for leaving:
Would you consider applicant for rehire?
If not, please explain:
Signature: Date:
Title:
 Facility:

 



The statements made in this application are true to the best of my knowledge. I understand that any falsification will be the basis for disqualification of employment or termination of services. I authorize White Glove to verify the information I have provided and to contact past employers and references concerning my ability, character and employment record. I release all such persons from liability for furnishing said information. I authorize White Glove, as my employer, to release any medical information, which may be relevant to my employment to their client facilities. By submitting this application to White Glove, I authorize release of this information to all other affiliates of the company and I acknowledge and agree that they may contact me using facsimile or any other means. Nothing contained in this employment application, or in the granting of an interview, is intended to create an employment contract between White Glove and the applicant for either employment or for providing of any benefit. All offers of employment are made conditional upon the applicant's proving employment authorization an identity in accordance with the Immigration Reform and Control Act of 1986.

I authorize White Glove and any third party payment contracted to obtain my criminal background information, motor vehicle records 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

 

 

Nursing Skills Checklist
Please select a maximum of 2 skills checklists that applies to your specialty and click on Continue

ICU/Critical Care Medical/Surgical Peds
Dialysis Nursery PICU
ER NICU Post Partum
L&D Operating Room Psychiatric
LPN/Long Term Care PACU Telemetry