LN Application

Dear Applicant,

Thank you for your interest in Greenline Health Services. In order to apply for the LN position, please fill out the online application below, as well as, be prepared provide updated originals (copies to be made at the office) of the following documents:

Please send copies of:

Resume
Driver’s License
Social Security Card
Current physical exam with immunization such as TB Test, Rubella, Rubeola, Varicella
CPR and other nursing training certificates (BLS OR ACLS)
State of Georgia Nurse Aide Certification, RN/LPN Georgia License
Car Insurance

Upon review of your application and the required documents, we will contact you for an initial interview and orientation. Please note, all documents must be completed before an orientation can be scheduled.

Best of luck!

Director of Clinical Services

Application for Employment - LN

Date
MM slash DD slash YYYY
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth
MM slash DD slash YYYY
Social Security Number
Contact Phone Home
Contact Phone Cell
Email
Emergency Contact
Emergency Contact Name
First Last
Emergency Contact Relationship
Emergency Contact Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Emergency Contact Phone
Position
Position Desired
Salary Desired
Applying For:
- Full Time Position
- Part Time Position
Indicate days and hours available to work
When are you available to start?
How did you hear about our Agency?
Employment History
Starting with the most recent, list your last two employers.
Employer#1 Name
Employer#1 From Date
MM slash DD slash YYYY
Employer#1 To Date
MM slash DD slash YYYY
Employer#1 Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employer#1 Phone
Employer#1 Duties and Responsibilities
Employer#1 Full Time Ending Rate/Hour
Employer#1 Part Time Ending Rate/Hour
Employer #1 May We Contact your Supervisor?
- Yes
- No
Employer #1 Supervisor Name
First Last
Employer #1 Supervisor Phone
Employer #1 Reason(s) for leaving
Employer#2 Name
Employer#2 From Date
MM slash DD slash YYYY
Employer#2 To Date
MM slash DD slash YYYY
Employer#2 Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employer#2 Phone
Employer#2 Job Title
Employer#2 Duties and Responsibilities
Employer#2 Full Time Ending Rate/Hour
Employer#2 Part Time Ending Rate/Hour
Employer #2 May We Contact your Supervisor?
- Yes
- No
Employer #2 Supervisor Name
First Last
Employer #2 Supervisor Phone
Employer #2 Reason(s) for leaving
General Employment Questions
Are you legal for employment in the United States?
- Yes
- No
Have you ever been convicted of a crime at any time, other than a minor traffic violation? A conviction (misdemeanor or felony) includes a plea of "guilty" or "no contest." ( A "yes" answer will be considered for job related purposes only and will not automatically disqualify you from employment).
- Yes
- No
If "yes," please explain:
Do you have any relatives working for Greenline Health Services?
- Yes
- No
Do you have previous employment existing under a different name?
- Yes
- No
If "yes," provide name
Educational History
High School Name
High School Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
High School: Select the number of years completed
- One Year
- Two Years
- Three Years
- Four Years
College / University Name
College / University Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
College / University: Area of Study or Degree
College / University: Select the number of years completed
- One Year
- Two Years
- Three Years
- Four Years
Other Educational Institute Name
Other Educational Institute Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Other Educational Institute Area of Study or Degree
Other Educational Institute: Select the number of years completed
- One Year
- Two Years
- Three Years
- Four Years
Professional Licenses, Registrations, and/or Certifications
NOTE: FOR ANY POSITION REQUIRING REGISTRATION, LICENSE, OR CERTIFICATION, ORIGINAL DOCUMENT MUST BE PROVIDED
Are you currently
- Registered
- Licensed
- Certified
Eligible for
- Registered
- Licensed
Will take Boards (list date)
#1 Type
#1 State Issued
#1 Date Expires
#1 Number
#2 Type
#2 State Issued
#2 Date Expires
#2 Number
CAPTCHA

LN Application

Application for Employment - LN

Emergency Contact

Position

Employment History

General Employment Questions

Educational History

Professional Licenses, Registrations, and/or Certifications