fill out job application form

Fill out our job application form

What type of nurse are you? *

Select *

Full Name *

Phone Number *

Date of Birth *

SSN#

Email Address *

Home Address/ Select

Spoken Languages

Has your professional license/certificate ever been investigated or suspended? *

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Do you have a current resume to upload?

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Please note: if your resume does bot reflect the necessary information needed, there will be additional documents to fill.

Level of Education Completed:

Name of College or Institution attended:

Address

Phone

IMPORTANT: Please provide 3 PROFESSIONAL References and 1 PERSONAL Reference. The 3 References MUST BE PROFESSIONAL REFERENCES. All references MUST INCLUDE a phone number AND a EMAIL ADDRESS. Enrty WILL NOT be accepted without contact information. Please Number them.

Must add ALL required references here

Experience 1

Employer name

Duration with Company

Address

Wages

Enter a number

POC

Still with current Employer?

May we contact?

Reason for leaving?

Titles and option

Experience 2

Employer name

Duration with Company

Address

Wages

Enter a number

POC

Still with current Employer?

May we contact?

Reason for leaving?

Titles and option

Please, upload your credentials

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PROFESSIONAL LICENSE/CERTIFICATION

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BLS/ACLS/PALS CARD

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PHYSICAL

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TB SCREENING

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DRUG SCREENING

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Employment, Education References

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CRIMINAL HX

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IDENTIFICATION

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SS CARD

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COVID VACCINE CARD

Were you referred by a LHS team member?

First &Last Name

How did you hear about us?

Loyal Hearts Staffing, LLC is an Equal Employment Opportunity employer and does not discriminate against any applicant or employee because of race, color, religion, national origin, sex, age, disability, or any other characteristic protected by federal, state, or local laws. If you believe that you have been discriminated against, please notify either your Manager, the Chief Operating Officer or the Vice President, Human Resources of Loyal Hearts Staffing, immediately. You may report an incident without fear of reprisal or retaliation. Reports will be investigated, and corrective action will be taken where appropriate. We assure that the opportunity for your employment with Loyal Hearts Staffing, is contingent solely upon your qualifications for the duties you are applying for.