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Advanced Health Care

Registered Nurse

AHC of Reno

Reno, Nevada

* Required fields

Personal Information

Name *

Other Names

Address *

City *

State *

Zip Code *

Home Phone *

Work Phone

Previous Address

City

State

Zip Code

Background Information

Have you ever been interviewed with AHC or its affiliates before? *

Yes No

Have you ever been employed by AHC or its affiliates before? *

Yes No

Are you eligible for re-hire? *

Yes No

Do you have any relatives employed by AHC or its affiliates? *

Yes No

Are you at least 18 years old? *

Yes No

Have you ever been convicted of a felony? *

Yes No

Have you ever been sanctioned or disciplined by any state or federal authority or excluded from participation in the Medicare or Medicaid programs under Sec. 1128 of the Social Security Act? *

Yes No

Employment Interests

Position desired: *

Full-time Part-time Per diem

Would you consider working any shift? *

Yes No

Weekends and Holidays? *

Yes No

Rotating shifts? *

Yes No

On call? *

Yes No

Do you have any medical and/or physical condition(s) or impairment(s) which may impact your ability to safely and effectively perform the duties of the position for which you are applying? *

Yes No

Salary desired

Education/Training

High School Education

Name and Address of Institution

Course of Study

Years attended

Diploma/degree?

College Education:

Name and Address of Institution

Course of Study

Years attended

Diploma/degree

Other:

Name and Address of Institution

Course of Study

Years attended

Diploma/degree?

Professional Licenses and/or Certificates

Currently, I am:

Registered Licensed Certified Applied for

Type

State

Date Issued

Expiration Date

Number

Currently, I am:

Registered Licensed Certified Applied for

Type

State

Date Issued

Expiration Date

Number

Current restrictions (if any)

Other special knowledge, skills, or qualifications

Employment History

Are you employed at present? *

Yes No

Please list your previous employers, starting with the most current or recent employer. Attach resume if necessary/available.

Employer Name

Phone Number

Employer Address

Employed From

Employed Until

Job Title

Ending Salary

Supervisor's Name

Duties & Responsibilities

Reason for leaving

Employer Name

Phone Number

Employer Address

Employed From

Employed Until

Job Title

Ending Salary

Supervisor's Name

Duties & Responsibilities

Reason for leaving

Employer Name

Phone Number

Employer Address

Employed From

Employed Until

Job Title

Ending Salary

Supervisor's Name

Duties & Responsibilities

Reason for leaving

References

Please list the names, titles, and phone numbers of three former supervisors, managers, or teachers other than relatives.

First Reference

Second Reference

Third Reference

Certification and Acknowledgement

Applicant Signature *

Date: *

Upload Resume:

Arizona

AHC of Glendale AHC of Mesa AHC of Scottsdale

California

AHC of Sacramento

Colorado

AHC of Aurora AHC of Colorado Springs

Idaho

Aspen

Kansas

AHC of Overland Park

Nevada

AHC of Henderson AHC of Las Vegas AHC of Paradise AHC of Reno AHC of Summerlin

New Mexico

AHC of Albuquerque

Utah

AHC of Salem AHC of St. George Aspen Ridge Aspen Ridge of Utah Valley Aspen Ridge West Pine View

Registered Nurse

AHC of Reno

Reno, Nevada

Personal Information

Background Information

Employment Interests

Education/Training

High School Education

College Education:

Other:

Professional Licenses and/or Certificates

Employment History

Please list your previous employers, starting with the most current or recent employer. Attach resume if necessary/available.

References

Certification and Acknowledgement

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