Nurses and Company Home Health, Hospice, and Private Services

If you would like to join us at Nurses and Company, you may submit an online application (or download our form here. )We look forward to hearing from you.

Please note that only complete applications will be considered.

PERSONAL DATA

Name (Last, First, MI)
Social Security #

Present Address City State Zip
Since (MO/YR)

Previous Address City State Zip
From (MO/YR) To (MO/YR)

Home Phone Cell Phone
Email Address

AVAILABILITY

Position Applying for: Start Date
Do you prefer If part time please specify days:
Sunday Monday Tuesday Wednesday
Thursday Friday Saturday
Can you work: Weekends

Please answer all of the following questions
Are you at least 18 years of age a legally eligble to work in the United States?
Yes No
Will you work overtime when neccessary? Yes No
Please list any restrictions you mights have on your ability to work overtime:
Have you ever been dismissed or asked to resign a job? Yes No
If yes, please explain
Have you ever been convicted of or pled guilty to a felony or other crime? Yes No
If yes, please explain
Have you ever been counseled or disciplined for violating a safety rule or engaging in unsafe behavior? Yes No
If yes, please explain

EDUCATION

Type of School	Name and City	Graduated	Course/Major
Grammar		Yes No
High School		Yes No
Junior College		Yes No
College		Yes No
Post Grad		Yes No
Trade		Yes No
Other		Yes No

EMPLOYMENT EXPERIENCE

Employer Phone
Address
From To
Position Held
Reason for Leaving Pay upon leaving
Duties

Have you ever applied with or been employed by Nurses & Company before? Yes No
If yes, give dates and position held
May we contact employers listed above? Yes No
if no please note which employers we may not contact:

References: List below the names of three(3) persons, not related to you, whom you have knwon at least one(1) year.
Name Address
Phone Number Occupation

Name Address
Phone Number Occupation

JOB RELATED SKILLS
Do you have reliable transportation? Yes No Do you have a valid drivers license? Yes No
Driver's License # Do you have any restrictions or endorsements on your driver's license? Yes No
If yes please list
Have you been convicted of or plead guilty to any traffic related offense within the past five (5) years? Yes No
Have you had your driver's license suspended, revoked or had your driving privileges modified by a court of law? Yes No
Are you registered with the Missouri family Care Safety Registy? Yes No
Typing Speed WPM Are you familiar with medical terminology? Yes No
Do you have computer experience? Yes No Please list software experience:
Please list any other professional licenses, skills, training, research, certifications which you feel are relevant to the position applied for. Include date granted, name of organization and any other relevant information.

Certification
I certify that I have read the instructions and note on page one (1) of this application and that the answers given by me herein are true and complete to the best of my knowledge and belief. I understand that should I be employed, employment shall be on a probationary basis. I further understand that upon completion of the probationary period, that my employment is for no definite period and may be terminated at any time without any previous notice. I also understand that if for any reason I am not hired that this application will be kept on file for a period of two (2) years and that I would need to reapply at that time. I hereby authorize any of my former employers or educational institution from any and all liability for any damages in furnishing such records.

This application form is intended for use in evaluating your suitability for employment. Please answer all questions completely and legibly. If a question is not applicable, indicate with N/A. False or misleading statements, whether oral or written, are grounds for refusal or termination of employment and benefits. All qualified applicants will receive consideration without discrimination on the basis of sex, marital status, race, age, creed, national origin, citizenship, disability, or any other status protected under state or federal law, and such information may be omitted from this form.

This application is not an employment contract. Additional testing of skills and other job-related characteristics may be required before an offer of employment is made. Once such an offer has been made, you will be required to undergo a medical review to determine your suitability for the position applied for. This review will include the completion for a medical history form and may include an examination by a medical professional (if proof of medical examination within the past six (6) months to one (1) year cannot be obtained).

Nurses & Company has a nurse clinician available for patient consultation 24 hours a day, 7 days a week.
636-926-3722 314-685-3722 or 618-310-1591