First Name:

Last Name:

Address:

Check the appropriate boxes below:
RN  LPN  NAC/NAR   

Phone: (___)___-____

Cell: (___)___-____

E-mail address- required

PREFERRED WORK AREA: Homecare Adult Family Home Visits All

Have you ever worked in homecare? If yes, how long?

Most recent experience?

How far are you willing to commute?

Do you have? (Check all that apply)
Current WA nursing license 
First Aid 
Current CPR card 
Food Handlers Permit 
Have taken 7 hr AIDS/HIV Training 
Vaccine History 
Current TB Test

HOMECARE EXPERIENCE: (Check all that apply)
IV
Vent
Adults
Peds
Trachs
Multiclient
School Nursing
Intermittent Visits
Hospice
Maternal Health - Mother/Baby

HOSPITAL EXPERIENCE: (Check all that apply)
MS
Tele
ICU
CCU
Peds
PP
L&D
Nursery
Clinic
Rehab
Detox
Jail
Psych
OR/Recovery
ER

SHIFTS PREFERRED:
Days
Eves
Nights
Full-time
Part-time

FYI TO PROSPECTIVE EMPLOYEE:

1. Alliance requires current copies of your nursing license, CPR card, social security card, WDL, and evidence of TB.
2. We will need 2 references before hire
3. In homecare, we cannot guarantee full- time days; flexibility with shift preference is a plus.
4. Drug free work place; pre-employment drug testing on site.
5. For licensed nurses: written medication exam.
6. A TB test within 3 days of hire will be required, even if testing has recently been completed. The exception to this is if applicant has previously tested positive, in which case a negative chest x-ray is required (no time limit on when x-ray was done). If no TB testing in the last year, a two step PPD will be required, so bring any TB info. Testing may be done at Alliance Nursing or the Health Dept. at no cost.