Personal Information

First Name: MI: Last Name:

Address:

City:   State:  Zip Code:

SSN:   Date of Birth:   Please use "MM-DD-YYYY" format!

Home Phone:    Work Phone:

Cell Phone:    Email:

We strongly encourage the use of email for ease of communication. If you do not have an e-mail address and wish to create one for free, you may do so here.

We are going to ask you to do routine testing through our online test center. Can you supply a password for this purpose? (If not, we will generate a random sequence for you.)

Enter it here: 

What is the best way and time to reach you?:

State/Driver's License:

In case of emergency, who is your Next of Kin?:

Their address:

Their phone(s):  

How did you hear about us, or who were you referred by? :

Have you lived outside of Florida in the last 5 years? -- No Yes

High School / City / State:

Year Last Attended: Graduated: No Yes

College / City / State:

Year Last Attended: Graduated: No Yes

Nursing or Other School / City / State:

Year Last Attended: Graduated: No Yes

Skill/Profession: RN LPN CNA HHA SITTER PT OT SP PTA OTA HomeMaker Other

Enter position applied for:  

General Area of Work Interest : Home Health Hospital Both

State / License: License Expiration Date:

State / License: License Expiration Date:

State / License: License Expiration Date:

Other Licenses:

BCLS Expires:    Please use "MM-DD-YYYY" format!

ACLS Expires:    Please use "MM-DD-YYYY" format!

Select all areas in which you have experience (use Control-Click to highlight multiple areas):

Med-Surg Cath Lab CCU CVICU ER GI - lab Home Health Home Infusion ICU L&D NICU Nursery OB-Gyn Postpartum Neurology Oncology PACU Peds Special Procedures Open Heart General OR Gyn OR CV-OR Ortho-OR Transplant-OR Tele SICU Psychiatry Dialysis Radiology Nuclear

Select areas of most interest to you (use Control-Click to highlight multiple areas):

Med-Surg Cath Lab CCU CVICU ER GI - lab Home Health Home Infusion ICU L&D NICU Nursery OB-Gyn Postpartum Neurology Oncology PACU Peds Special Procedures Open Heart General OR Gyn OR CV-OR Ortho-OR Transplant-OR Tele SICU Psychiatry Dialysis Radiology Nuclear

What Shifts are you available to work?   Days     Evenings     Nights

We require that you have worked continuously for the past five years. If you have had more than three employers in the past five years, then email your other employment information to hr2@nfhsonline.com. If you have a special situation, contact the office staff by email at hr@nfhsonline.com with your explanation. In addition, if, during the past five years, you did not hold a job due to enrollment in high school or college please have that educational institution send official transcripts to our office.

By listing employment references below you are giving North Florida Health Services permission to contact these employers. If you show gaps in employment history below because you do not wish for us to contact certain employers, please send reasoning and explanation to hr2@nfhsonline.com.

List starting with current or most recent:

Employer:   Supervisor:

Phone:   Your Position:

Dates Employed (express as MM/YY - MM/YY):  

Employer:   Supervisor:

Phone:   Your Position:

Dates Employed (express as MM/YY - MM/YY):  

Employer: Supervisor:

Phone: Your Position:

Dates Employed (express as MM/YY - MM/YY):  

Have you ever been arrested or convicted of a felony? -- No Yes

Have you had a malpractice claim made? -- No Yes

Have you had any sort of disciplinary investigation or action against your professional license? -- No Yes

Are you now or have you ever been in an impaired professional program? -- No Yes

Have you been injured on the job? -- No Yes

Have you ever filed a Workman's Compensation Claim? -- No Yes

Have you ever been paid Workman's Compensation? -- No Yes

Have you ever been terminated from or asked to quit a job? -- No Yes

What foriegn languages do you speak?

How far (miles) or in what areas of town or surrounding areas are you willing to work?

Initialed by Applicant:

If you are a CNA or HHA looking to work in Home Health, we require, prior to checking your references, for you to complete these forms. Please note that the scenario on page 2 should be used to fill out page 3. Please scan and e-mail, fax, or mail the completed forms to our office. Below is our contact information:

Human Resources
North Florida Health Services
710 North 3rd Street
Jacksonville Beach, FL 32250
Fax: (904) 241-0883
E-mail: hr@nfhsonline.com

I certify that this information is correct and acknowledge that its accuracy is subject to verification by this agency. I understand that furnishing incorrect or misleading information will render this application void and will be just cause for termination.