Nursing Careers

Name

Phone Number

Position Interested In

RN
LPN

License Number (if applicable)

In which state was your license issued? (if applicable)

Years of Experience as a Nurse

0 - 1 year
2 - 5 years
6 - 9 years
10 or more years

Areas of Interest

Tell us about your nursing experience (1000 words or less)

Have you been previously employed by Tallahassee Memorial HealthCare (TMH)?

Yes
No

Have you ever been convicted by law enforcement authorities for any violation of law, regulation or ordinance? This includes pending convictions, pleas of nolo contendere, deferred adjudication, adjudication withheld and pardoned, including all felonies, misdemeanors, traffic violations, excluding traffic misdemeanor convictions.

Yes
No

If yes, please describe the incident(s) including dates.

Have you ever been terminated or suspended from employment?

Yes
No

If yes, please describe including when.

If yes, please enter the name and relationship of relative.

Do you currently meet the legal requirements to work in the United States?

Yes
No

Has your RN License ever been restricted, revoked or subject to other disciplinary action against your clinical license?

Yes
No

Is there any reason you would be unable to fully perform the job as described?

Yes
No

I acknowledge I will be required to obtain an active RN License authorizing me to legally practice nursing in the State of Florida prior to beginning employment as an RN at TMH. Please type in your initials to acknowledge.

I acknowledge that I have filled out this online application to work at Tallahassee Memorial HealthCare on my own free will and did not enlist another person or entity to complete the application on my behalf. Is this statement true?

Yes
No

Please type in your initials to acknowledge the statement above as factual.

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