AMP Nurses

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Personal Information
Last Name:
First Name:
Middle Initial:
Maiden Name:
Address:
City:
State:
Zip:
Permanent Mailing Address:
City:
State:
Zip:
Day Time Phone:
Evening Phone:
Cell Phone:
Social Security Number:
Driver License:
Education (Post Graduate)
Program:
Address:
# Years Attended:
Degree Obtained:
Education (Nursing College)
Program:
Address:
# Years Attended:
Degree Obtained:
Graduation (yyyy-mm):
Military (complete this section if you served U.S. Armed Force)
Branch of Service:
From (yyyy-mm):
To (yyyy-mm):
Rank at Discharge:
Date of Discharge (yyyy-mm):
Describe Your Duties and any Special Training:
Were you honorable discharge?:	Yes No
Certification
State of original Licensure:
All states of Licensure:
Professional Organizations to Which You Belong:
Professional Liability Insurance Carrier (If Applicable):
Amount of Coverage:
Expiration Date (yyyy-mm):
Work History/Employment #1
Employer's Name:
Supervisor's Name:
Telephone:
Address:
City:
State:
Zip Code:
Title of Position:
Dates Employed (yyyy-mm):
Ending Salary:
Department:
Reason For Leaving:
Description of Duties:
May we contact?:	Yes No
Work History/Employment #2
Employer's Name:
Supervisor's Name:
Telephone:
Address:
City:
State:
Zip Code:
Title of Position:
Dates Employed (yyyy-mm):
Ending Salary:
Department:
Reason For Leaving:
Description of Duties:
May we contact?:	Yes No
Work History/Employment #3
Employer's Name:
Supervisor's Name:
Telephone:
Address:
City:
State:
Zip Code:
Title of Position:
Dates Employed (yyyy-mm):
Ending Salary:
Department:
Reason For Leaving:
Description of Duties:
May we contact?:	Yes No
Health
Date of your Last Examination by a Physician:
Do you have Any Physical / Health limitation that might affect your ability to practice as a Nurse?:	Yes No
If yes, please explain:
Person to notify in case of Emergency #1
Name:
Relationship:
Day time Telephone:
Evening Telephone:
Address:
City:
State:
Zip Code:
Person to notify in case of Emergency #2
Name:
Relationship:
Day time Telephone:
Evening Telephone:
Address:
City:
State:
Zip Code:

Have You Ever Been Dismissed From Employment of Drug Use / Addiction or Ever Been Treated for Drug Use / Addiction?:	Yes No
If yes, explain:
How did You Hear About Advanced Medical Placement?:
Please specify:

I HEREBY CERTIFY THAT THE INFORMATION PRESENTED HEREIN IS MOST AUTHENTIC, TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I FURTHER UNDERSTAND THAT ANY MISGUIDED OR FALSE STATEMENT WILL BECOME BASIS FOR DISQUALIFICATION FOR MY EMPLOYMENT OR TERMINATION OF SERVICES WITHOUT ANY FURTHER NOTICE. I ALSO FULLY AUTHORIZE AMP TO REVIEW AND VERIFY ALL INFORMATION SET FORTH IN THIS APPLICATION, INCLUDING BUT NOT LIMITED TO REFERENCES, STATE LICENSURES AND INSURANCE POLICY VERIFICATIONS.

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