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Nursing Management, Inc.

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Order Number

Page 1: Introduction

Equal access to programs, services and contract work is available to all persons. Applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resource Department.

Position Applied For *

Date of Application *

How did you hear about us? *

Newspaper Relative Walk-in Employee Website Other

Last Name *

Middle Name

First Name *

Physical Address

Address *

City *

State *

Zip *

Mailing Address

Is your mailing address the same as the above address?

Yes No

Address *

City *

State *

Zip *

Home Phone *

Cell Phone

Email *

Page 2: Introduction (cont.)

Have you submitted an application with NMI before? *

Yes No

Have you ever been contracted through NMI previously? *

Yes No

Have you ever pled Guilty, or No Contest To, or been Convicted of a crime? *

Yes No

List any special accomplishments, publications, awards, etc.

Page 3: Education and Certifications

High School Name

High School Year Graduation

Name of College

College Year Graduation

Type of College Degree

Name of Nursing School

Nursing School Year Graduation

Type of Nursing School Degree

Any other University or school? *

Yes No

State Boards

Date

Critical Care Course

Date

CPR Certified? *

Yes No

ACLS Certified? *

Yes No

First Aid Certified? *

Yes No

Page 4: License Information

For Registered, Licensed Practical Nurses, and Certified Personnel.

License No

State

License Expiration Date

Do you have a current physical?

Yes No

PPD?

Yes No

Have you ever had disciplinary action against any of your nursing licenses or certificate?

Yes No

Do you have reliable transportation? *

Yes No

Do you have valid insurance? *

Yes No

Do you have a valid driver's license? *

Yes No

Do you have a telephone available to communicate with NMI? *

Yes No

Page 5: Course Certifications

Course Title

Hours

Provider

Course Title

Hours

Provider

Personal References

List three persons not related whom you have known for at least one year.

Reference Name *

Business *

Phone *

Number of years known *

Reference Name *

Business *

Phone *

Number of years known *

Reference Name *

Business *

Phone *

Number of years known *

List any additional information you'd like us to consider

Page 6: Work Information

List most recent or present employer first. *If any of the employers listed below are agencies, please provide the agency name and the hospital where you worked.

Are you currently employed? *

Yes No

Employer 1 (most recent)

Employer Name

Address

Position Held

Specialty

Phone Number

Start Date

End Date

Employer 2

Employer Name

Address

Position Held

Specialty

Phone Number

Start Date

End Date

Employer 3

Employer Name

Address

Position Held

Specialty

Phone Number

Start Date

End Date

Page 7: Type of Work Desired

Hospital Staff Relief:

Nursing Home

Hospital

Doctor Office

Private Duty:

Home Care/Visits

Respite Nursing

Private Duty

Personal Care:

Companion

Hospice

Can Work *

Saturday Sunday Monday Tuesday Wednesday Thursday Friday

What shift times are you available? *

Morning Afternoon Evening Night All

Experience Checklist

Check those areas shown below in which you are currently competent and willing to do

Client Types and Conditions

Alcoholism

Blindness

Heart Condition

Confusion/Disorientation

Convulsive Disorders

Geriatrics (Elderly)

Multiple Sclerosis

Parkinson's Disease

Para/Quadriplegic

Cancer

Stroke

Burns

Diabetes

Mental/Physical Disable

Infant/Child Care

Nursing Specialties

ICU (Medical)

ICU (Surgical)

ER/Trauma

Medical/Surgical

Operating Room

Team Leader/Medical Nurse

Head/Charge Nurse

Labor/Delivery

Nursery/Newborn

Neonatal ICU

Occupational Health

Rehabilitation

Orthopedics

Recovery Room

School Health

Hospice

Oncology

Phsychiatry

IV Therapist

Neurology

Community Health

In-Service Instructor

Pediatrics

Gerontology-Elderly

Office-Clinic

Tasks and Skills

Alternating Pressure Mattress

Bed Sores (Decubiti)

Bladder Catheterization-Male

Bladder Catheterization-Female

Bladder Training

Bowel Training

Gastrostomy-Tube Feeding

Central Venous Pressure

Remove Fecal Impaction

Hypo/Hyperthermia Blanket

Clean Bathroom

Light Ironing

Crutchfield Tongs

Cardiac Monitors

Fracture-Cast Care

Fracture-Traction

Dialysis-Peritoneal

Dialysis-Renal

Digital Stimulation

Hyperalimentation

Irrigation-Colostomy

Irrigation-Ear/Eye

Mop Kitchen/Bathroom

Personal Laundry

Irrigation-Ileostomy

Isolation Techs

Medications

NG Tube Insertion

NG Tube Irrigation

Postural Drainage

Post Mortem Care

Foley Cath-Insertion

Foley Cath-Irrigation

Foley Cath-Removal

Meal Planning

Drive as Needed

Circo-Electric Bed

Special Diets

Sterile Techniques

Stryker Frame

Suctioning

Gavage Feeding

Tracheostomy Care

Subclavian Dressing/Change

Suprapubic Catheter/Care

Oxygen Delivery Systems

Vacuuming

Cooking

Venipuncture

Food Pumps

Oncology

Ventilators

Dishes

Dusting

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Agreement of Terms

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I agree to the Privacy Policy found on our Privacy Policy page linked above.

Authorization *

I authorize investigation of all statements contained in this application. I understand that misrepresentation of omission of facts is cause for dismissal. Further, I understand and agree that my contract is for no definite period and regardless of date of payment of my wages, I may be placed inactive at any time without previous notice.

Page 8: Summary

Summary of your Submissions

Please review your submissions carefully. If you need to make any adjustments, please do do by going back and doing so. When you're ready, please click submit your application below.

Nothing is More Important Than Meeting the Needs of Our Clients.

Gulf Coast: 228.385.9196
Hattiesburg: 601.584.9196
Toll Free: 800.448.3634