Job Application

Applicant Full Name: *

First

Last

Home Address: *

Address Line 1

City

State

Number of years at this address: *

Daytime phone: *

Evening phone:

Mobile phone:

Driver's License (State/Number): *

Gender: *

Email Address: *

Contact Name: *

Who should be contacted if you are involved in an emergency?

Address: *

Address Line 1

City

State

Relationship to you: *

Mobile phone: *

Job Position Applied For: *

Salary Desired (In USD Per Month) *

Full or Part Time? *

Who referred you to our company?

Do you have any friends or relatives who work here? If yes, please list here:

Have you applied to our company previously?

Are you at least 18 years old?

How will you get to work? *

Are you willing to work any shift, including nights and weekends? *

If no, please state any limitations: *

If applicable, are you available to work overtime? *

If you are offered employment, when would you be available to begin work? *

If hired, are you able to submit proof that you are legally eligible for employment in the United States? *

Are you able to perform the essential functions of the job position you seek with or without reasonable accommodation? *

What reasonable accommodation, if any, would you request? *

Registered Nurse (RN) Years of Experience

Licensed Practical Nurse (LPN) Years of Experience

Certified Nursing Assistant (CNA) Years of Experience

Others (Name and list the years of experience)

Applicant Employment History: *

List in this order:-
Employer Name:
Supervisor Name:
Address:
City/State/ZIP:
Job Duties:
Reason for Leaving:
Dates of Employment (Month/Year):

College/University Name and Address *

Did you receive a degree? *

Degree/Certificate Earned:

High School/GED Name and Address *

Did you receive a degree? *

Other Training (graduate, technical, vocational):

Please indicate any current professional licenses or certifications that you hold.

CPR
BLS
ACLS
CPI

As part of employment, immunizations are required upon hire and annually as follow. Please provide copies of taken within the last year: *

Tuberculosis
TB Quantiferon
PPD
Covid 19: Initial
Booster

Military Service: *

Branch:

Specialized Training

References *

List in this order:-
Name:
Address:
City/State/ZIP:
Telephone:
Relationship:

Please provide any other information that you believe should be considered, including whether you are bound by any agreement with any current employer:

CERTIFICATION *

I HAVE CAREFULLY READ THE ABOVE CERTIFICATION AND I UNDERSTAND AND AGREE TO ITS TERMS.

I certify that the information provided on this application is truthful and accurate. I understand that providing false or misleading information will be the basis for rejection of my application, or if employment commences, immediate termination. I authorize Kemtos Inc to contact former employers and educational organizations regarding my employment and education. I authorize my former employers and educational organizations to fully and freely communicate information regarding my previous employment, attendance, and grades. I authorize those persons designated as references to fully and freely communicate information regarding my previous employment and education. If an employment relationship is created, I understand that unless I am offered a specific written contract of employment signed on behalf of the organization by its CEO, the employment relationship will be "at-will." In other words, the relationship will be entirely voluntary in nature, and either I or my employer will be able to terminate the employment relationship at any time and without cause. With appropriate notice, I will have the full and complete discretion to end the employment relationship when I choose and for reasons of my choice. Similarly, my employer will have the right. Moreover, no agent, representative, or employee of Kemtos Inc, except in a specific written contract of employment signed on behalf of the organization by its CEO, has the power to alter or vary the voluntary nature of the employment relationship.

Resume:

Click or drag a file to this area to upload.

Attach your resume if available.

Preferred Contact Method: *

Phone
Email

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KEMTOS INC NURSES COMPETENCY CHECKLIST

KEMTOS INC. CNA AND MHT COMPETENCY LIST