EMPLOYMENT APPLICATION (Printable Version)

 

In order to register with us please complete all the fields in the “Resume Form” below, providing us with your Personal and Career Information (Mandatory).   All information is confidential.  After we review your resume, we will contact you to discuss all your options.

If you already have a resume you can e-mail to us at nurses@thomasbrowngroup.com.  However, you MUST complete this “Resume Form” below and submit it electronically.  Direction for submission is found at the end of this form.

Date:

 

Employment and Certification Information

Last Name

 

First Name and Initials:

 

Street address and City:

 

 

 

State/province

Postal Code:

Email:

 

Present Position:

 

Tel. #:

Position Desired:

Fax. #:

Do you prefer to be contacted by:

Email Phone Both

Briefly give some reasons for wanting to work in the United States:

 

 

 

 

 

Choose American State where you prefer to work:

 

 

Choose American City where you prefer to work:

 

State your Nursing Specialties:

Registered Nurse (RN)

License Practical Nurse (LPN)

Certified Registered Nurse

Anesthetist

Certified Nurse-Midwife

Certified Nurse Practitioner

Advanced Practice Registered Nurse (APRN)

Clinical Nurse Specialist

Other:

 

Check if you have clinical experiences in those areas:

School health

Occupational health

Rehabilitation nursing

Emergency room nursing

Critical care

Operating room

Oncology

Pediatrics

Geriatrics

Other

 

Desired Work Status: Full time  Part-time

 

Type of institution you prefer to work in:

Are you licensed to work in:  United States  Canada Other (specify )

 

Are you a  United States:

 Citizen

Valid US Green Card Holder

Valid US Work Visa Holder (specify type)

 

Are you a  Canadian:

Canadian Citizen

Canadian Landed Immigrant Status
Valid Canadian Work Visa Holder (specify type)

Which type of professional license(s) or affiliation(s) do you hold from your country of residence? Specify Country:

Valid License (#1) (specify type):

Valid License (#2) (specify type):

Valid License (#3) (specify type):

Do you hold membership(s) in professional organizations?

 Name of organization (#1):

 Name of organization (#2):

 Name of organization (#3):

 

Please indicate the number of years you have worked full-time in your specialty:

Less than 1 year 1 year 2 years 3 years 4 years
5-7 years 8-10 years Over 10 years   

 

Current Employment History:

Name  of institution

 

Type of institution:

Street Address and City:

# of Beds in Institution:

State/Province/Country:

Postal Code:

 

Current Specialty:

Position Title:

 

Date Position Started:

 

Supervisor’s  Phone:

Name Supervisor:

 

Supervisor’s FAX:

Supervisor’s Cell

 

May we contact supervisor for a reference?    Yes  No

Supervisor’s  E-mail:

 

Please describe special job-related skills gained as a result:

 

 

 

Previous Employment History:

Name  of institution

 

Type of institution:

Street Address and City:

# of Beds in Institution:

State/Province/Country:

Postal Code:

 

Specialty:

Position Title(s):

 

Date Position Started:

 

Supervisor’s  Phone:

Name Supervisor:

 

Supervisor’s FAX:

Supervisor’s Cell

 

May we contact supervisor for a reference?    Yes  No

Supervisor’s  E-mail:

 

Please describe special job-related skills gained as a result:

 

 

 

 

 

Previous Employment History:

Name  of institution

 

Type of institution:

Street Address and City:

# of Beds in Institution:

State/Province/Country:

Postal Code:

 

Specialty:

Position Title:

 

Date Position Started:

 

Supervisor’s  Phone:

Name Supervisor:

 

Supervisor’s FAX:

Supervisor’s Cell

 

May we contact supervisor for a reference?    Yes  No

Supervisor’s  E-mail:

 

Please describe special job-related skills gained as a result:

 

 

 

 

 

Education

Diploma/Assoc Degree: (Date, Name of degree, Academic institution, city,       country):

 

 

Bachelor's Degree: (Date, Name of degree, Academic institution, city, country):

 

 

Master's Degree: (Date, Name of degree, Academic institution, City, country):

 

 

PhD: (Date, Name of degree, Academic institution, City, Country):

 

 

Other: (Date, Name of degree, Academic institution, City, Country):

 

 

Job-Related Courses –Identify courses which you have taken that are related to your job. Indicate dates received, names and locations where the course(s) were taken:

 

 

Other related Professional Memberships, affiliations, licenses, etc.:

 

 

 

Language ability:

My native language is English

I speak and write English fluently

I speak and write French fluently

I speak basic Spanish for       healthcare job-related needs

I speak and write Spanish fluently

I also speak and write:

Work Experience—Please describe your work experience from the year you've started  working as a nurse to the present:

 

 

 

 

 

 

 

 

 

 

Resume— If you have a resume already prepared, you can attach it to this Application (optional) or You can also email your resume to nurses@thomasbrowngroup.com