• Address

    1885 De La Cruz Blvd., Suite 205
    Santa Clara, CA 95050

  • Working Hours 9:00AM - 4:00PM

  • Call Us (408) 275-5910

Application Form

Nurses R Us Personal Data

Hours Desired

  • 40/Wk
  • < 40/Wk
  • On Call
  • Any

Shifts Available

  • Days
  • Evenings
  • Nights
  • Any

Days Available

  • Sun
  • Mon
  • Tue
  • Wed
  • Th
  • Fr
  • Sat
Preferred locations/site(hospitals, nursing homes, clinics, etc) of interest to work , Make a list. (City, State)

Professional Licensure

Applicant Declaration

Are you 18 or older?

  • Yes
  • No

Are you eligible to work in the United States legally?

  • Yes
  • No

Have you ever been convicted, pled guilty or no contest to a crime? This includes misdemeanors (except parking violations), gross misdemeanors and felonies. A conviction, guilty plea or no contest will not necessarily disqualify you for employment consideration.

  • Yes
  • No
  • If yes, gives dates and explanation (where, when, etc):

Have you ever been excluded from the Medicare or Medicaid program for conduct that would constitute a misdemeanor, gross misdemeanor or a felony under the law?

  • Yes
  • No

Have you ever been disciplined by professional or state ethics or licensing board?

  • Yes
  • No

Educational Information

    Did You Graduate?

  • Yes
  • No

    Did You Graduate?

  • Yes
  • No

    Did You Graduate?

  • Yes
  • No

    Did You Graduate?

  • Yes
  • No

Employment Information

Equal Employment Opportunity Questionnaire

    Sex

  • Male
  • Female

What Racial/Ethnic Category Do You Consider Yourself

  • American Indian or Alaskan Native

All persons having origins in any of the original people of North America.

  • Asian or Pacific Islander

All persons having origins in any of the original people of East, Southeast Asia, the Pacific Islands or Indian subcontinent. This area includes for example China, Japan, The Philippines Island, and Samoa.

  • Black

Not of Hispanic Origin. All persons having origins in any of the Black racial groups.

  • Hispanic

All persons of Mexican, Puerto Rican, Cuban, Central or South America, or other Spanish culture or origin.

Disabled Veteran

Are you entitled to disability compensation under laws administered by the Veterans Administration for disability rates at 30% or more, or are you a person whose discharge or release from active duty was for a disability incurred or aggravated in the line of duty.

  • Yes
  • No

Handicapped

    Do you (1) have a physical or mental impairment which substantially limits one or more major life activities, (2) have a secure record of such impairment, (3) are regarded as having such an impairment, or (4) have experienced difficulty, retaining or advancement in employment because of your handicapped?

  • Yes
  • No

Our company is committed to respectful and equal treatment for all employees. This commitment includes non-discrimination towards applicants and employees on the grounds of race, color, creed, religion, age, sex, disability, national origin, ancestry, sexual orientation, marital status, or with regard to public assistance, or union or non-union status. This prevails throughout the employment relationship, including, but not limited to recruitment, selection, training, transfer, compensation, promotion, demotion, layoff and termination.

Work Related References (No family members, relatives, or personal friends)

    May We Contact This Person For A Reference

  • Yes
  • No

Applicant Release, Please read and sign below

I authorize the investigation of my background including all information contained in this application and information provided in the interview. I understand that misrepresentation or omission of information in connection with my application and interview will be sufficient cause, in and of itself, for rejection or dismissal whenever discovered. I understand and agree that any offer of employment is contingent upon satisfactory completion of Nurses R Us pre-employment investigation which includes but is not limited to health assessment, criminal history check, educational and work verification, reference checks, consumer report and any investigation required by local, state, or federal laws. I understand that if I am hired by Nurses R Us, my employment will be for an indefinite period of time and will be "ATWILL" which means that either Nurses R Us, or I may terminate the employment relationship at anytime and for any reason or no reason.

I further understand that, if hired, my "AT-WILL" employment status may only be changed in written contract signed by the management of Nurses R Us, and that no representative of Nurses R Us has the authority to make oral promise to me concerning my employment. Finally, I also understand that Nurses R Us may adopt, from time to time, policies or handbooks dealing with benefits and other terms or conditions of employment. These policies or handbooks do not constitute a contract of employment between Nurses R Us and me. Nurses R Us reserves the right to change or discontinue these policies and/or handbooks at any time with or without notice to me.

Nurses R Us strives to provide a safe, healthy and productive work environment and supports a smoke free, alcohol-free work environment.


SIGNATURE OF APPLICANT, DATE

FULL NAME OF APPLICANT (Please Print)