-  Blue Leaf Process
-  Candidate Registration
-  Job Listings
 
 
 
Whether you are looking for per diem positions or permanent positions,
Blue Leaf will find the right position for you!  Please fill out the form below
or call 212-382-2935 to schedule an interview.  We look forward to
working with you.

Employment Application
* Indicates required information
   
 
  Social Security Number:
  Birthday: / /
* Name:
  Maiden Name:
  Current Address :
  City:
  State:
  Zip Code:
* Phone: - -
* Work Phone: - -    Ext:
* Cell Phone: - -
* Emergency Phone: - -
* E-mail address:
  Who referred you to
  Blue Leaf Group?:
 
  Shift Preference:
  (check all shifts that you would be interested in working)
  How many hours per week
  would you like to work:
  Days: 8Hr 12Hr weekday weekend
  Evenings: weekday weekend
  Nights: 8Hr 12Hr weekday weekend
  Do you work double shift?: Yes No Occasionally

  Would you be willing
  to work holidays:

Yes No
  What hospitals/clinics are
  you interested in staffing?:
  Nursing Units worked
  in the past year
  Related Courses/
  Certifications
  (i.e. balloon pump, cvvhd,
  ekg, chemo, ecmo):
 
  Education:
  Name and location of schools:
* High School:
* Month/Year graduated: /
* College/University:
* Month/Year graduated: /
* Nursing School:
* Month/Year graduated: /
* Check all that applies to you:
  ADN BSN MSN PhD Diploma
 
  Employment Experience (most recent first, RN position only)
  Employment Dates:
  From: / To: /
  Hospital:
  Part Time:
  Full Time:
  Address:
  City:
  State:
  Zip:
  Specialty/Unit:
  Charge Nurse Experience: Yes No
  Supervisor:
  Reason for leaving:
 
  Employment Dates:
  From: / To: /
  Hospital:
  Part Time:
  Full Time:
  Address:
  City:
  State:
  Zip:
  Specialty/Unit:
  Charge Nurse Experience: Yes No
  Supervisor:
  Reason for leaving:
 
  Employment Dates:
  From: / To: /
  Hospital:
  Part Time:
  Full Time:
  Address:
  City:
  State:
  Zip:
  Specialty/Unit:
  Charge Nurse Experience: Yes No
  Supervisor:
  Reason for leaving:
 
  Agency Employment:
  Have you ever worked
  for other agencies prior
  to Blue Leaf Group?:
Yes No
  Name of Agency:
  From: / To: /
  Hospitals/Units worked :
  Name of Agency:
  From: / To: /
  Hospitals/Units worked :
  Name of Agency:
  From: / To: /
  Hospitals/Units worked :
 
  Professional References: Please provide us with the home/work
  numbers of one supervisor and one co-worker that you have worked
  with in the past year.
  Name:
  Shift:
  Work Phone: - -
  Home Phone: - -
  Manager:
  Co-Worker:
  Charge Nurse:
  Name:
  Shift:
  Work Phone: - -
  Home Phone: - -
  Manager:
  Co-Worker:
  Charge Nurse:
 
  Employment Questions:
  Has your nursing license
  ever been suspended?:
Yes No
  If yes, Why?:
  Have you ever been
  terminated from a
  previous employer?:
Yes No
  If yes, Why?:
  Have you been convicted
  of a felony?:
Yes No
  If yes, explain?:
  Is your job performance
  affected by any physical   limitations?:
Yes No
  If yes, what?:

  Have you ever been
  involved in malpractice
  or New York/New Jersey
  Department of Professional
  Regulation disciplinary
  proceedings?:

Yes No
  If yes, explain?:

  Have you been asked to
  not
return to a
  hospital/clinic through
  another agency?:

Yes No
  If yes, what agency and
  hospital?:
  Why?:
 
Application Statement:
The statements made in this application are true and accurate.  I understand that any falsification or omission will be the basis for disqualification of employment or termination of services.  I authorize Blue Leaf Group to verify the information I provided, & to contact past employers & references concerning my ability, character & work habits.  I release such persons from liability for providing such information.  I authorize Blue Leaf Group to release to their clients any information from my file (including medical information) which may be relevant to my employment. I understand that my employment is an employment at will, and may be terminated at any time without prior notice.  Blue Leaf Group is an equal opportunity employer*.
I agree No, I disagree
   
 

 

 
 
 
Copyright © 2007 Blue Leaf Group, Inc. All rights reserved. Phone: 212-382-2935 Fax: 212-584-9957 Email: HR@blgny.com