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First Name |
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Last Name |
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Address line 1 |
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Address line 2 |
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City/Town |
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State/ Province/ County |
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Postal Code |
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Country |
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Email |
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Phone |
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Discipline |
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Specialty |
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Secondary Specialty |
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Years of Nursing Experience |
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Type of Nursing Education |
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Name of College |
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Month/Year Graduated |
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I attest that the information provided in this application is complete and accurate,
to the best of my knowledge. Providing incomplete or inaccurate information may
result in disqualification from the program, and may be a violation of state law(s)
that could result in civil penalties. The Company is authorized to obtain information
from my current and previous employers, and to release information in support of
my application (application, references, background search results, etc.) to the
Company's client institutions and to appropriate governmental or licensing entities.
The Company may also share applicant information with its affiliates. I understand
that the Company, certain states and/or Client institutions may require criminal
background checks, and I consent to such checks. Prior to conducting any background
checks that qualify as consumer or investigative consumer reports, I will be provided,
and will return, separate disclosure and acknowledgement forms as required by the
Company.
I agree with the above statements.
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