Nursing Staff Application - S&R Nursing Recruiting Services

Full Name

First

Last

Email Address

Phone Number

Social Security # (for background checks)

Specialization

Address

Address Line 1

Address Line 2

City

State

Zip Code

Professional Licenses & Certifications (Required for Connecticut)

RN
LPN
CNA

License & Education

License Expiration Date

Other State Licenses Held (if applicable):

Basic Life Support (BLS) Certification:

Yes
No

Expiration:

Advanced Certifications (ACLS, PALS, etc.):

Section 3: Education & Training

Nursing School Attended

Degree/Diploma Earned:

ADN
BSN
LPN
CNA Program

Year Graduated

Clinical Specialties (if any)

Availability & Preferences

Days
Nights
Weekends
PRN (as needed)

Shifts Available

Full Time or Part Time

F/T
P/T

Preferred Work Setting

Hospital
Nursing Home
Home Health
Clinic

Geographic Preferences (CT Regions)

Have You Ever Had A Professional License Disciplined?

Yes
No

If yes, explain:

Criminal Background Check Consent:

Yes (Agency Will Process)

TB Test Results (Current within 1 year):

Yes
No

COVID-19 Vaccination Status:

Fully Vaccinated
Exemption

Work History:

Upload Resume

Drag & Drop Files, Choose Files to Upload

Acknowledgment

By submitting this form, you confirm that all provided information is accurate.