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APPLICATION

Apply to join our team

Apply to join our team

Apply to join our team

Tell us a little about yourself and the role you are interested in. Fields marked with an asterisk are required.

Tell us a little about yourself and the role you are interested in. Fields marked with an asterisk are required.

Promise Health Care Nursing Service NJ Inc. is an equal opportunity employer. All applicants and employees are considered for employment, advancement, and development based upon their skills, performance, and potential. No current or prospective employee will be discriminated against because of race, creed, color, gender, age, national origin, handicap, or military status.

Availability

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Date Available for Employment (required)

Position Applying for (required)

Name

First Name (required)

Last Name (required)

Middle Name (required)

Date of Birth (required)

Social Security Number (required)

Contact Information

Phone Number — Country (required)

Phone Number (required)

Email (required)

Address

Country (required)

Address Line 1 (required)

Address Line 2

City (required)

State (required)

ZIP Code (required)

Education

Start and Finish Dates, School, Location, and Degree/Diploma (required)

Start and Finish Dates, School, Location, and Degree/Diploma (required)

Start and Finish Dates, School, Location, and Degree/Diploma

License (RN, LPN, HHA)

License/Certificate Type (required)

License # (required)

State (required)

Expiration Date (required)

License/Certificate Type (required)

License # (required)

State (required)

Expiration Date (required)

Health Clearances & Insurance

CPR Expiration Date (required)

Last Physical Exam Date (required)

Lab TB / Chest X-Ray Date (required)

Name of Applicant’s Malpractice Insurance Carrier (required)

Policy Number of Applicant’s Malpractice Insurance Carrier (required)

General Information

Are you legally authorized to work in the USA? (required)

If you become an employee of Promise Healthcare Nursing Service NJ Inc, you will be required to provide documentation proving your eligibility to work in the USA.

Have you ever been convicted of a felony, misdemeanor, or crime? (required)

The presence of a criminal record is not an automatic rejection of your application. I attest that the information provided is true and accurate and authorize employment and background verification.

Referral Information

How did you hear about us? Please check. (required)

Insert the newspaper, website, current employee, or “other”. (required)

Emergency Contact Information

First Name (required)

Last Name (required)

Relationship (required)

Phone Number (required)

Address — Country (required)

Address Line 1 (required)

Address Line 2

City (required)

State (required)

ZIP Code (required)

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