Print Form Professional Respiratory Network Inc. 1010 Sycamore Avenue, Ste. 102, South Pasadena, CA 91030 • Telephone: 323 474 0914 • Fax: 323 474 0915 • E-mail: [email protected] • Web: http://www.prnregistry.com Personal Information (please print) Today’s Date First Name Middle Initial Address City Home Phone Work Phone Cell Phone E-mail Are you under 18 years of age Last Name State Yes No Zip Social Security # Conviction or arrest (please select one) Please exclude any convictions for which the record has been judicially ordered sealed & expunged. Have you ever been convicted of a felony? Yes No Yes No Yes No If Yes Have you ever been convicted of a misdemeanor? (Misdemeanor includes trafﬁc convictions) If Yes Have you ever been arrested for a sex-related offense? (Answer only if the job for which you are applying has regular access to patient.) If Yes Have you ever been arrested for a drug-related offense? Yes No (Answer only if the job you are applying for has access to drug/ medication.) If Yes Desired Position Educational Record Type of School High School or GED Neonatal RN Adult RN Name & Location Neonatal RCP Adult RCP Did You Graduate? Yes No College or University Yes No Vocational School Yes No Respiratory /Nursing School LVN/CNA Yes No Major & Degree if no highest grade completed Licensure/ Certiﬁcation RN LVN RCP License Number Expiration Date Other current licenses/certiﬁcation: Have you ever been terminated or asked to resign from any job? Yes If Yes No Please explain any gaps in your employment history within the last 10 years Begin with the most recent employer. Major change in duties should be listed as a different job. Include temporary and volunteer experience. Employer Name Job Title Department Address City State Full-time Detailed account of duties & experiences Part-time Avg Weekly Hours Work Experience (within last 10 years) Per diem ____/______ from (Mo/Yr) Supervisor’s Name & Title Starting Hourly Salary Zip ___/______ from (Mo/Yr) Supervisor’s Phone (must be completed) Ending Hourly Salary Employer Name Job Title Department Address City State Full-time Detailed account of duties & experiences Part-time Avg Weekly Hours Per diem ____/______ from (Mo/Yr) Supervisor’s Name & Title Starting Hourly Salary Zip ___/______ from (Mo/Yr) Supervisor’s Phone (must be completed) Ending Hourly Salary Employer Name Job Title Department Address Detailed account of duties & experiences City State Zip Full-time Part-time Per diem ____/______ from (Mo/Yr) Avg Weekly Hours ___/______ from (Mo/Yr) Supervisor’s Name & Title Starting Hourly Salary Professional Respiratory Network be completed Supervisor’s Phone (must ) Inc. 1010 Sycamore Avenue, Ste. 102, South Pasadena, CA 91030 • Telephone: 323 474 0914 • Fax: 323 474 0915 Ending Hourly Salary • E-mail: [email protected] • Web: http://www.prnregistry.com Employer Name Job Title Department Work Experience (within last 10 years) Address City State Full-time Detailed account of duties & experiences Part-time Avg Weekly Hours Per diem ____/______ from (Mo/Yr) Supervisor’s Name & Title ___/______ from (Mo/Yr) Supervisor’s Phone (must be completed) Starting Hourly Salary Ending Hourly Salary Employer Name Job Title Department Address City State Per diem ____/______ from (Mo/Yr) Supervisor’s Name & Title Zip Full-time Detailed account of duties & experiences Part-time Avg Weekly Hours ___/______ from (Mo/Yr) Supervisor’s Phone (must be completed) Starting Hourly Salary Certiﬁcation (All Applicants) Zip Ending Hourly Salary I understand that a condition of employment is my ability to provide documentation of eligibility to work in the United States in compliance with the immigration reform act of 1986. I certify that the answers given by me to the foregoing statements are correct and without omissions. I authorize Professional Respiratory Network (The Company) to investigate the foregoing and any other information that might assist in determining my qualiﬁcations for employment. I also authorize all persons and institutions, including my previous employers and the schools that I attended, to provide the company with any information that it requests in connection with this investigation. I release the company and my former employers, persons contacted, and schools from all liability for any damage that may result from any such investigation. I understand that, if employed, false statements or omissions of material information from this application, or any other document submitted in connection with the hiring process, may result in my termination at any time during my employment. If employed, I agree to abide by all company polices. I understand that this employment application and any offer of employment are not to be construed as a guarantee of employment for a speciﬁed time. I further understand that my employment is terminable at will, either by myself or my employer upon notice of one party to the other. I acknowledge, where required, I will maintain any and all required certiﬁcation and or licensure as a condition of employment. I acknowledge that I have read all of the above statements and that I understood them. I certify the above is true to the best of my knowledge. Signature Print Name Date