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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.

Click here to return to the home pageThis 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).
 
 
Personal Data
Name 
Social Security #
Present Address


Since (MM/YY) 		Previous Address


Since (MM/YY)
Home Phone
Work Phone
 
Availability
Position(s) Applied For Date You Can Start
Do You Prefer:
If Part-Time, specify days: 		Can you work:  
 
Education
School Name and City   Graduate Course/Major
High School
  Yes
No
Junior College
  Yes
No
College
  Yes
No
Post Graduate
  Yes
No
Business/ Trade
  Yes
No
Other
  Yes
No
 
Employment Experience
1. Employer Position Held
Address
Dates
Phone Supervisor
Duties
2. Employer Position Held
Address
Dates
Phone Supervisor
Duties
3. Employer Position Held
Address
Dates
Phone Supervisor
Duties
May we contact the employers listed above?  Yes No
If no, please note which employers we may not contact:
 
Job-Related Skills
Do you have a valid Driver's License?  Yes No
State of Issue: License Number:
Do you have any computer experience? Yes No
Have you ever been convicted of or pled guilty to a felony or other crime?
Yes No
Are you at least 18 years of age and legally eligible for work in the United States? Yes No
Please list any other professional licenses, skills, certifications, or qualifications, which you feel are relevant to the position applied for.  Include date granted, name of organization, and any other relevant information.

 
 
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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
Nurses & Company 115 Piper Hill Drive, Suite 200, St. Peters, Missouri 63376
St. Charles County 636-926-3722   St. Louis County 314-685-3722  Fax 636-926-3872
Illinois 618-310-1591