Nurse / Caregiver Questionnaire

1Personal Info

2General

3Talents/Specialties

4Additional Comments/Notes

Resume sent in to J Danielle?
- Yes
- No
Letters of Recommendation & References sent in?
- Yes
- No
(need at least 3 professional references)
Photo for your profile submitted?
- Yes
- No
Copies of Certifications?
- Yes
- No
Full time, Part time, Temp?
- Full time
- Part time
- Temp
Long term availability?
- Yes
- No
Available Days/Hours?
Location preference?
Open to relocating?
- Yes
- No
Live-in or Live-out?
- Live-in
- Live-out
- Either
Pay rate approx. range desired?*

(Please indicate hourly or salary)
Are you a US citizen or green card holder?
- US Citizen
- Green card holder
Please specify which*
Okay with background check if client requests one?
- Yes
- No
(National and International)
Middle initial & year born?
Clean DMV record?
- Yes
- No
CPR certified?
- Yes
- No
Fingerprinted?
- Yes
- No
Why did you leave your last job?