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Foreign Nurses Application Form
PLEASE FILL ALL FIELDS BEFORE SUBMITTING THE FORM

Personal Information:
Prefix:	Mr. Miss. Mrs.
Complete Name :

Please Choose a Username & Password:
username :
password :

Current Address Information:
Address :
City :
Country :
Phone Number:
Email Address :
Today's Date (M/D/Y):

Current Employer:
Employer Name :
City :
State :
Country :
Employed from :

Previous Job
Employer Name :
City :
State :
Country :
Employed from :
Employed to :

Nursing School Information:
Name of School :
Mailing Address :
City :
Country :
Degree :
Date of Qualification :
Website :

Nursing Experience
Medical or Surgical ?	Yes No
Number of Months ?
Operating Room ?	Yes No
Number of Months ?
Critical Care?	Yes No
Number of Months ?
Other Experience Describe:
Number of Months ?
Have you complete the VISA Screen ?	Yes No
Date Issued :
if not, when do you plan to apply :
Do you have a CGFNS Certificate ?	Yes No
Date Issued :
if not, when do you plan to apply :
Have you passed the NCLEX :	Yes No
Date Issued :
if not, when do you plan to apply :
Have you Worked in another Country ?	Yes No
Where :
From :
To :
Do you have any relatives in the US ?	Yes No
City :
State:
Do you have any Health Problems ?	Yes No
Please, Describe
Do you have Physical Limitations ?	Yes No
Please, Describe
Give us your feedback

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PLEASE READ CAREFULLY

I certify that the statements made on this application are true and correct to the best of my knowledge and belief and hereby grant NursingJobsAmerica.com permission to verify such answers. I understand that any false statement on this application will be considered as sufficient cause for rejection of this application or for dismissal if such false statement is discovered subsequent to my employment. I authorize written access to any records concerning my education or employment background. I understand, that if, any inquiry is made, all information as to its nature and scope will be supplied upon written request. I will have to pass a post-employment physical examination, as a condition of employment. If this application is considered favorably, I agree to abide by and comply with all the employer’s rules. Your ability to complete this application clearly and effectively will be considered requirement for the job for which you are applying.

NursingJobsAmerica.com is an equal opportunity employer. We comply with all applicable laws of the State of Florida and the Federal Government regarding employment practices. These statutes prohibit discrimination in employment based on race, color, sex, age, nationality, creed, and physical or mental disability.