Nurse Application Form

STATESIDE NURSING INTERNATIONAL

Nurse Application Form

INTERNATIONAL NURSES

Please complete the application form to the best of your ability.

The * indicates a required field.

* First name:
* Last name:
* Email address:
* Address 1:
Address 2:
* City:
State:
* Postal Code:
* Country:
* Phone:
Mobile Phone:
Have You Worked Overseas Before?
Which Country(ies)?
How did you hear about Stateside Nursing International?
Do you have friends or family members who are under contract with SNI?
* Are you under INS Petition or Contract with another Agency or Hospital?
If YES, please explain (when contract ends, why you are looking for a new position, etc.)
* School of Nursing 1:
City1:
Country 1:
School of Nursing 2:
City 2:
Country 2:
Nursing License Country:
License Expiration Date:
Nursing License Country 2:
License Expiration Date 2:
* Have you passed or are you currently registered to sit NCLEX?
* Where did you take NCLEX?
When did you take or register for NCLEX?
* Have you passed or are you registered for CGFNS?
CGFNS Number:
CGFNS Date:
* Have your credentials been evaluated by CES?
* Do you have a Visa Screen Certificate?
* Have you taken an English Test?
*If Yes, which one?
Employer Hospital 1:
Number of beds in hospital:
City:
Country:
Employment Dates:
Position Held:
Where in the USA would you like to work?
Is there another State you'd like to work?
Date available to travel or relocate:
Is there anything else you can tell us to help us find you a position?
* Have you ever been convicted of a criminal offence?
If Yes please indicate details here:
* To the best of my knowledge the preceeding information is true and correct:

phone: (303) 926-7461 fax: (303) 926-0496
USA & Canada: 1-888-698-1964

P.O Box 39
Louisville, CO 80027