Healthcare Nurse Registry Application

Healthcare Nurse Registry Application

Application Date:

Applicant Information

Date of Birth:    Gender:

Phone:    Email:

Licensure, Certification, and Credentialing

Select all professional credentials held:
Registered Nurse (RN)    Licensed Practical Nurse (LPN)    Certified Nursing Assistant (CNA)    Advanced Practice RN (APRN)    Other

License Issue Date:    Expiration Date:

Expiration Date:

Insurance / Liability

Policy Number:    Effective Date:

Education and Training

Employment History (Most Recent First)

Position Held:    Dates Employed From:    To:

Position Held:    Dates Employed From:    To:

Health, Immunizations, and Screening

Result:

Professional Conduct and Legal History

Have you ever had a professional license disciplined, revoked, suspended, limited, or placed on probation?   Yes   No

Have you ever been convicted of a misdemeanor or felony, pled nolo contendere, or entered a diversion program?   Yes   No

References

Authorizations, Attestations, and Disclosures

I certify under penalty of perjury that the information provided in this application is true, correct, and complete to the best of my knowledge. I understand that falsification, omission, or misrepresentation of information is grounds for denial of placement on the registry or termination if discovered after placement.

I authorize the registry, its agents, and contracted entities to verify any information provided, including but not limited to education, professional licensure, employment history, immunization records, and malpractice insurance. I further authorize third parties to release information to the registry upon request.

I consent to a criminal background check, including fingerprinting if required by the registry or contracting facilities. I also consent to drug screening and understand that placement is contingent upon satisfactory results.

I understand that placement on the registry does not guarantee assignment, employment, or any specific number of hours, and that the registry may deny placement for reasons including failure to meet credentialing requirements, unsatisfactory background checks, or health and safety concerns.

Privacy and Release

I acknowledge that the registry maintains records necessary for credentialing and placement. I authorize release of relevant health, employment, licensure, and disciplinary information to contracting facilities and authorized agents for purposes of placement and quality assurance. I release all persons and entities from liability for furnishing such information in good faith.

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