Job Application: Nurse Practitioner- Tensas Clinics The documents accessed from the links below must be read and understood prior to submitting an application. Standards Of Performance Expectations Statement Of Understanding And Release Title: Nurse Practitioner- Tensas ClinicsFields marked with an asterisk (*) must be filled out before submitting.Contact DetailsFirst NameLast NameEmail AddressAddress CityStateZipTelephoneCell phoneQualificationsHave you ever been employed with Franklin Medical Center? Yes NoIf yes, please list department and dates:Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? (Proof of citizenship/immigration status is required upon employment.) Yes No Date available to start Minimum salary requirementIndicate type of employment Full Time Part Time PRNIndicate days available to work Monday Tuesday Wednesday Thursday Friday Saturday SundayIndicate shifts available to work Days NightsPosition desired Certified Nurse Aide RN Radiology Respiratory Therapy LPN Housekeeping Dietary Maintenance Pharmacy Lab Surgery Office/Clerical IT OtherIf other was selected please explainCurrent EmploymentCompany NameJob TitleCompany Address (Street,City,State,Zip)TelephoneName of Supervisor/TitleEmployment DatesReason for LeavingCurrent SalaryJob Duties Previous EmploymentCompany NameJob TitleCompany Address (Street,City,State,Zip)TelephoneName of Supervisor/TitleEmployment DatesReason for LeavingBeginning SalaryEnding SalaryJob Duties Company NameJob TitleCompany Address(Street,City,State,Zip)TelephoneName of Supervisor/TitleEmployment DatesReason for LeavingBeginning SalaryEnding SalaryJob Duties EducationDo you have a high school diploma or GED? Yes NoHighest education level achieved? High School Diploma or GED Associate’s Degree Bachelor’s Degree Master’s Degree Ph.D.Name & Location of School# of hours completedGPADegree/MajorDate Degree Obtained Skills & CertificationsLicense/Certification (include License #, Issuer, Issue and Expiration Dates) Have you ever been convicted of a felony? Yes NoIf yes, please explain, and give dates: Have you ever been involuntarily discharged from a job? Yes NoIf yes, please explain, and give dates: List any experiences, skill or qualifications which you feel uniquely qualify you for work with our organization: List any professional organizations of which you are a member: ReferencesPlease list three personal/professional references(include contact information) * I have read and understood the STANDARDS OF PERFORMANCE EXPECTATIONS and the STATEMENT OF UNDERSTANDING AND RELEASE.