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Personal Information: First Name: Last Name: Email: Address: City: State: Choose Outside US Alabama Alaska American Samoa Arizona Arkansas California Canal Zone Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Mariana Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Zip Country: Phone: Cell Phone: Professional Information: Classification: Choose Medical Doctor (MD) Registered Nurse (RN) Nurse Practitioner Licensed Practical Nurse (LPN) Licensed Vocational Nurse (LVN) Certified Nurse Assistant (CAN) Medical Assistant Certified Occupational Therapy Assistant (COTA) Occupational Therapist Physical Therapist (PT) Physical Therapy Assistant EEG Technician Surgical Technologist Other Refferal Source: Choose... Walk-In Newspaper Magazine Friend Employment Agency Online Relative Email Other Work Status: Choose... U.S. Citizen Need U.S. H-1 Visa U.S. Permanent Resident U.S. F-1 Visa Holder U.S. H-1 Visa Holder Russian Citizen Other Date Avialbale: mm/dd/year Employment Profile: Professional License No: Licensure State: Background: Are you presently employed? Yes | No May we contact your present employer? Yes | No Have you ever applied with this company before? Yes | No Has your License ever been revoked investigated or suspended? Yes | No Are you willing to take a drug screen test by our policies? Yes | No Marital Status: Single | Married | Divorced | Widdowed Do you have children under 18 years of age? Yes | No Have you ever been convicted of a felony? Yes | No Last Physical: mm/dd/year Employment Experience: Start with your present or last job. Include military assignments and volunteer activities. Exclude organizational names which indicate race, color, religion, sex or national origin. Facility Name: No. of Beds: Facility Address: Position: Employment Dates: Background: Teaching Facility? Yes | No Trauma Facility? Yes | No Staff Employee? Yes | No Manager/Supervisor? Yes | No Charge Experience? Yes | No Facility Name: No. of Beds: Facility Address: Position: Employmen Dates: Background: Teaching Facility? Yes | No Trauma Facility? Yes | No Staff Employee? Yes | No Manager/Supervisor? Yes | No Charge Experience? Yes | No Facility Name: No. of Beds: Facility Address: Position: Employmen Dates: Background: Teaching Facility? Yes | No Trauma Facility? Yes | No Staff Employee? Yes | No Manager/Supervisor? Yes | No Charge Experience? Yes | No Education: High School Name: Address: Degree: Vocational/Tech School Name: Address: Degree: College/University Name: Address: Degree: College/University Name: Address: Degree: Specialized Training: English proficiency exam within the last two years? TOEFL | TOEIC | IELTS If yes, which exam(s) and what was your score? Application Legal Disclaimer By completing this application of employment for Global Nursing Alliance, Inc. ("GNA"), you hereby agree to all of the following statements, terms and conditions: I understand and agree that any employment by GNA and myself is predicated upon the truthfulness of the statements made in this application and accompanying correspondence. I understand that any misrepresentations or omissions of facts called for is cause for immediate dismissal. In connection with this application for employment, I authorize GNA, and/or its agents and/or its representatives, to make a complete, thorough and independent investigation of my background and to verify and make any and all inquiries deemed necessary concerning the information I have provided including the authorization to contact any persons, business entities, educational institutions, governmental agencies, law enforcement agencies, past or current employers and references for the purpose of reviewing my employment record, confirming any and all statements given to GNA or other information developed in connection with this application, determining my qualifications and abilities to GNA's satisfaction, or to comply with federal or state law; or to comply with the policies and procedures of GNA's clients. In furtherance of this application for employment, I authorize any and all persons business entities, educational institutions, governmental agencies, law enforcement agencies, past or current employers and references to provide GNA with any information concerning my character, current and/or prior employment performance, education, criminal background and professional licensure/certification standing without any liability whatsoever to them or GNA. I hereby release GNA and/or its agents or representatives, without reservation or condition, including any person, business entities, educational institutions, governmental agencies, law enforcement agencies, past or current employers and references from any and all liability arising from, created by, or caused by the release of any such personal or business information, records and related documents to GNA, its agents and/or representatives. A copy of this release is acceptable in lieu of the original document. I understand that if employed by GNA, I will be an employee 'at-will' and that I or GNA may terminate any employment at any time. I understand and agree that GNA retains the sole discretion to offer assignments to employee(s) that it believes, in its sole discretion, is most qualified for the assignment and would best represent the business interests of GNA. By selecting the "I have read and agree to the terms of the Application Legal Disclaimer" option in the GNA Staffing Online Application, I, the applicant, agree to have read, understood, and accepted the terms listed in the above Legal Disclaimer, and I sign this Legal Disclaimer voluntarily, without coercion or duress from any individual or party. I have read and agree to the terms of the Application Legal Disclaimer

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