Application Part One

Please give the below application a moment to load. Carefully complete all sections of our Employment Application and Nursing Skills Test prior to your interview. Required fields appear in bold. You will receive email confirmation when you have finished the final section. If you need assistance, please call (919) 872-7999 or send an email to staffing@phicare.com

Contact Data

First Name Last Name

Likes to be called License # RN/LPN

Residential Address



City State Zip

Mailing Address Check if same as residential



City State Zip

Email Address if you have no email enter info@phicare.com

Cell Phone Please send text messages about open shifts
Cell Provider (required to send texts)

Home Phone

Please list any other numbers where you may be reached

Alternate 1

Alternate 2

Alternate 3

Emergency Contact Information
Name Relationship Phone

Name Relationship Phone

Name Relationship Phone

How long have you lived in North Carolina?



How did you hear about Professional Healthcare, Inc?



How many driving offenses have you had in the last 5 years?



Have you ever been convicted of a crime other than a minor traffic violation?

If yes, please explain in paragraph below.


Education

High School Attended Graduated Year
If no graduation, did you complete your GED? Year GED Location

Nursing School Attended Degree Year

Nursing School Attended Degree Year

List any other skills, trainings, or certifications.

Work History

Company/Facility Phone

Title/Position From Until

Did you supervise others? Starting Wage Ending wage

If yes, how many

Description of duties in paragraph form.


Reason for leaving

Supervisor's Name

May we contact this employer or supervisor?




Company/Facility Phone

Title/Position From Until

Did you supervise others? Starting Wage Ending wage

If yes, how many

Description of duties in paragraph form.


Reason for leaving

Supervisor's Name

May we contact this employer or supervisor?




Company/Facility Phone

Title/Position From Until

Did you supervise others? Starting Wage Ending wage

If yes, how many

Description of duties in paragraph form.


Reason for leaving

Supervisor's Name

May we contact this employer or supervisor?

References

Professional Reference

Name Phone Fax

Employer From To

Personal/Professional Reference

Name Phone Fax

If your second reference is a professional reference please provide the following information
Employer From To

Please list any additional references. We will need to verify two references before you begin training.



The people listed above may be contacted for a reference and may release employment information about me

(required) I agree that the above information is true and can be verified by PHI. If employed, any false statements on this application/interview will be grounds for termination. I agree to uphold the policies and procedures of PHI and keep both company and client records confidential. I also agree to comply with all conditions of employment required by PHI. I understand that if hired, my employment is for no definite period of time and may, regardless of the date of payment of wages, be terminated at any time without notice or cause.


Error? Be sure you completed all sections in bold and checked the required acknowledgements