Roberta Chambers, Nurses Connection, recruit, work in the U.S., nursing, career opportunities

For more than a decade, Roberta Chambers has been championing the rights of individuals like you in the areas of

Application For Employment
For consideration, application should be filled out in full.

Personal Information
The information contained herein will be considered confidential and is the property of Nurses Connection.

Name:		Last, first, middle initial

Mailing Address:

Permanent Address :

City:

State:

Zip:

Country:

Country Code:

Phone Number:

Alternate Phone:

Email Address:

In Case Of Emergency, Call:		Name
		Relationship
		Phone

Education
1. High School:
Year:
Major/Special Training/ Certification:

2. High School:
Year:
Major/Special Training/ Certification:

3. High School:
Year:
Major/Special Training/ Certification:

College:
Major:
Degree:
Date of Graduation:

Employment Record & References
Indicate a continuous record of employment beginning with your most recent position. Include military.
1. Employer/Company:
Address:
Phone:
Employment Dates:		From:
		To:
Supervisor Name:
Position Held:
Reason for Leaving:
May We Contact This Employer?		Yes
		No
If No, Please Explain:

2. Employer/Company:
Address:
Phone:
Employment Dates:		From:
		To:
Supervisor Name:
Position Held:
Reason for Leaving:
May We Contact This Employer?		Yes
		No
If No, Please Explain:

3. Employer/Company:
Address:
Phone:
Employment Dates:		From:
		To:
Supervisor Name:
Position Held:
Reason for Leaving:
May We Contact This Employer?		Yes
		No
If No, Please Explain:

Personal References
(Exclude family members)
Name:
Address:
Phone:
Email:
Relationship:

Name:
Address:
Phone:
Email:
Relationship:

Have You Ever Been Convicted Of A Crime?		Yes
		No

If Yes, Please Specify: (Conviction is not an automatic bar to employment)