Corporate Phone: (586) 771-4097

We are an equal opportunity employer and will not unlawfully discriminate on the basis of race, color, sex, religion, national origin, age, marital or veteran status, the presence of a medical condition of handicap, height, weight, or any other protected status. Please Note: This application will take approximately 15 minutes to complete. If you are contacted for an interview you will be given an opportunity to review and modify any submitted information.

* Indicates information is required
 

GENERAL INFORMATION

 

Please enter your full legal name as it appears on your Social Security card

 

Last Name*              

Maiden Name          

First Name*              

 

Middle Name           

 

Today's Date            

Current Address*

 
 Current City*                             Current State*       Current Zip*

                     

Current Phone*

     

 Note: Enter a ten digit number (i.e. Do not use parentheses , dashes, or spaces).

 Example: 9876543210
                                                                                  

Cell Phone               

        

Note: Enter a ten digit number (i.e. Do not use parentheses , dashes, or spaces).

Example: 9876543210

 

E-Mail*                 

 

Previous Address   


 Previous City                              Previous State    Previous Zip 

      

Position Applied For:*  



Applicant Classification*  
(At least one classification selection is required but you may choose up to three classifications you are qualified for)



 

Applicant Unit  
(Select Up to three)

 

 

 

 

Applicant Desired Facility*  
(At least one facility selection is required but you may choose up to three)




Contract Type*

 

Days / Shift Times Available to Work

 

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

 

Do you have one year of experience, in the position you are applying for,  within the last two years?*

 
GENERAL QUESTIONS

Are you 18 years old or older?*
Are you a US Citizen?*
  
Are you authorized to work in the US?*
Have you been previously employed here?*
If applicable, dates of previous employment:
Have you filed an application here before?*
If applicable, previous dates you have filed application:
How were you referred?

If applicable, enter name of Independent Nursing Services employee who referred you?
Have you ever had your nursing license suspended or revoked?*
If yes, list dates and nature of the case:
Have you been convicted of any crime since the age of 18?*

If so, where, when and the nature of the offense?
Do you have a driver's license?*

Were you ever discharged or forced to resign from any position?*
If yes, please explain:

EMERGENCY INFORMATION

Emergency Contact  


 Emergency Address 


 Emergency City                          Emergency State    Emergency Zip

                         
Emergency Phone     

       

Note: Enter a ten digit number (i.e. Do not use parentheses , dashes, or spaces).
EMPLOYMENT HISTORY

Employer 1    


Address         


City                                                State      Zip

              
May we contact?

Phone            

       

Note: Enter a ten digit number (i.e. Do not use parentheses , dashes, or spaces).

 

Job Title        


Supervisor     


Date Started  


Date Left       


Hourly Rate   


Starting Rate 


 Reason For Leaving 

Type of work performed:


Employer 2    


Address         


City                                                      State      Zip

             

May we contact?

Phone           

       

Note: Enter a ten digit number (i.e. Do not use parentheses , dashes, or spaces).
Job Title       


Supervisor    


Date Started 


Date Left       


Hourly Rate   


Starting Rate


 Reason For Leaving


Type of work performed:

 

Employer 3    


Address         


City                                                State     Zip

              

May we contact?

Phone           

       

Note: Enter a ten digit number (i.e. Do not use parentheses , dashes, or spaces).

 

Job Title       


Supervisor    


Date Started 


 Date Left      


Hourly Rate  


Starting Rate


 Reason For Leaving


 Work Performed

EDUCATION

Education/Certification 1
Name and Location
Did you graduate?

Degree Or Certificate

Education/Certification 2
Name and Location
Did you graduate?

Degree Or Certificate

PROFESSIONAL REFERENCES

Professional Reference Name 1 
Job Title
Address
City                                                          State    Zip
              
Phone
        

Note: Enter a ten digit number (i.e. Do not use parentheses , dashes, or spaces).

 

Years Acquainted

Professional Reference Name 2
Job Title
Address
City                                                          State    Zip
              
Phone
        

Note: Enter a ten digit number (i.e. Do not use parentheses , dashes, or spaces).

 

Years Acquainted

 

Below are important employment policies for INS. Please read the policies below then click submit at the end of these policies to have your application sent to INS.

Read this doc on Scribd: AllESigDocs

 

BY CLICKING ON THE SUBMIT BUTTON, YOU ACKNOWLEDGE THAT The information provided is true and that you have read and understand the employee policies listed here. YOU CONSENT TO USING ELECTRONIC METHODS FOR ALL THE PURPOSES LISTED ABOVE AND HAVING ALL RECORDS PROVIDED OR MADE AVAILABLE TO YOU IN ELECTRONIC FORM.

After you have clicked "Submit" please be patient as your data is being saved.
A checklist of required items will load after your application has been submitted successfully.

Please call us the next day to make sure we received you application. Phone 586-771-4097
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