Healthcare LPN Application

HEALTHCARE LPN APPLICATION

Please complete this application fully and legibly. All statements are subject to verification. Incomplete or illegible applications may delay consideration. By signing, the applicant certifies the information provided is true and consents to verification of credentials, references, and background checks as described below.

Personal Information

Date of birth:    Gender: Male Female Other

Emergency Contact

Are you legally authorized to work in this country? Yes No

Licensure and Certifications

License expiration date:

CPR / BLS    ACLS    IV Therapy    Other:

Date of most recent certification renewal (enter MM/DD/YYYY):

Education

Degree or diploma:    Graduation date:

Employment History (Most recent first)

Supervisor:    Position held:

Dates employed: From To

(Provide prior employer information on additional sheet if necessary.)

Professional References

Health, Immunizations and Occupational Requirements

TB test (PPD or IGRA) date: Result: Negative Positive

MMR:    Varicella:

Tdap date:    Hepatitis B series complete: Yes No

Background, Discipline and Legal History

Have you ever been convicted of a felony or misdemeanor which has not been annulled, expunged, or sealed? Yes No

Has any disciplinary action been taken against your nursing license, certification, or professional privileges? Yes No

Have you ever been the subject of a malpractice claim? Yes No

Authorization, Certification and Consent

By checking the box below and signing, I certify under penalty of perjury that the information provided in this application is true and complete to the best of my knowledge. I understand that falsification, omission or misrepresentation of information may be grounds for denial of employment or immediate termination if employed.

I certify that the information provided is true and complete.

I authorize the employer to contact educational institutions, current and former employers, licensing authorities, and references to obtain information concerning my qualifications, work history, character, and licensure. I release and hold harmless any person or entity that provides such information and the employer from liability for providing and using such information.

I authorize a criminal background check, drug screening, and verification of professional licenses and certifications as a condition of consideration for employment. This authorization remains valid until the Authorization Expiration Date below unless revoked in writing.

I understand that employment is at-will and that either I or the employer may terminate employment at any time, with or without cause or notice, unless a written agreement states otherwise.

Confidentiality and HIPAA: I acknowledge that as a licensed caregiver I will be entrusted with protected health information. I agree to comply with all confidentiality and privacy policies and applicable law, and I understand that unauthorized use or disclosure of patient information may result in disciplinary action, up to and including termination.

I acknowledge and agree to comply with confidentiality and privacy requirements.

Applicant Statement

I understand that this application is not an employment contract. I authorize investigation of all statements contained in this application and release all persons from liability for any damages that may result from furnishing such information. I agree to submit to drug testing and background checks as required by the employer as a condition of employment.

Sign Now