SURVEY

Job Code or Position Applied For

Where did you hear about us?    

PERSONAL INFORMATION

Last Name:   

First Name:   

Middle Initial:

      Gender: Male  Female

 

Street Address/Apt:

   Province/Division:

             Town/City:

    County/Zip Code:

 

           Home Phone:

Alternate/Cell Phone:

         Email Address:                  

 

Nationality:

Language other than English:

   DOB:       Birth Place:

            mm/dd/yyyy                                        province / city / country

 

  Status: Married Single DivorcedOther

  If Married, enter date of marriage:

                                                     mm/dd/yyyy

 

Spouse Full Name: 

Spouse Birth Place:

Spouse Birth Day:  

Spouse Nationality:

 

Children? Yes No

If Yes, please list children below starting from your first child.

 

Child1: Full Name:

Child1: Birth Place:

Child1: Birth Date: 

 

Child2: Full Name:

Child2: Birth Place:

Child2: Birth Date: 

 

Child3: Full Name:

Child3: Birth Place:

Child3: Birth Date: 

 

If there are more child, please list them below:

 

EDUCATION/TRAINING

High School: 

Date Graduated: Years Attended:

                          (mm/dd/yy)                     ex. (5yrs or 6mo)

 

College/Univ:

Date Graduated: Years Attended:

Degree:

 

Other/Training:

Date Graduated: Years Attended:

Degree/Certification:

EMPLOYMENT HISTORY

** List the last 3 years or last 3 employers starting with the most recent one.

Employer:

Address:  

Phone:    Position:

Inclusive Dates:

Duties Performed:

 

Employer:

Address:  

Phone:    Position:

Inclusive Dates:

Duties Performed:

 

 

Employer:

Address:  

Phone:    Position:

Inclusive Dates:

Duties Performed:

 

IMMIGRATION REQUIREMENTS

NCLEX-RN Exam:  Yes No

If YES, Date Taken:  

ID Number:

Passing Score:

CGFNS Certificate: Yes No

If YES, Date Taken:  

ID Number:

Passing Score:

ENGLISH QUALIFYING EXAMS:

 

Choose One: TOEFLIELTS TSE  TWE

If selected, Date Taken:  

ID Number:

Passing Score:

VISA SCREEN CERTIFICATE:  Yes No

If YES, Date Taken:  

ID Number:

OTHER

Preferential Geographic Area(s) to be placed: ex. Los Angeles

Are you currently being sponsored (either by another employer or a relative in the United States, for an Immigrant/or H1-B Visa? If YES, please explain below:

 

Do you have any health conditions that may affect or impair your

  ability to work? If yes, explain treatment or medications below.

 

Use the space below for special notes you want us to know about

   that may be related to the position you are applying for.