OnLine Application
Answer all questions completely. Applications are evaluated on completeness and accuracy.
General Information
Position applying for: Specialization:
First Name:     M.I.     Last Name:
DOB: Place of Birth:
Sex:
Male Female
Nationality:
Home Phone: Cell Phone:
Office Phone: E-mail address:
Address:
City, State ZIP: ,  
Emergency Contact: Emergency Phone:
Emergency Contact Address:
Civil Status
Single Married Widow Separated
Current Employment
Are you currently employed in a hospital?:
Yes No
Hospital Name:
Hospital Address:
Bed Capacity of the Hospital:
Bed Capacity of the Unit:
Nurse to Patient Ratio:
Hours per Week:
Schedule
Full Time Part Time Volunteer

Are you under an existing contract?:
Yes No
Time Remaining on Contract:

Are you required to give notice prior to leaving?:
Yes No
Qualification
Exam Exam Date Rating Attempts Issued on Valid Until
PRC Licensure Exam
CGFNS Exam
NCLEX - RN Exam
TOEFL/TWE/TSE/TOEIC Exam
IELTS Licensure Exam
Visa Screen Certificate
CGFNS/ICHP Username: CGFNS/ICHP Password:
Education
Education Month/Year Graduated Name of School/Address Degree Received
College or University
Post Graduate
Other Courses
Seminars/Training
Other languages spoken/written:
Employment History
Employer From To Unit Assigned Time at Position (Yrs./Mos.) Schedule
Immediate Family
Spouse DOB
Children DOB
Review Programs Attended
Program Date Duration Result Location
CGFNS
NCLEX -RN
IELTS
TOEFL/TWE
TSE
TOEIC
References
Name Title Address Telephone

Visa Information
Passport Number: Issuing Country:
Date Issued: Date Expires:

Have you ever been to the United States?:
Yes No
Type of US Visa:
Date Visa Issued: Date Visa Expires:
Are you presently, or have you previously been sponsored for an immigrant visa, or working visa in the U.S.?: Yes No
If Yes, Case Numbers

Additional information
Memberships and Affiliations
Summary of Experience and Qualifications
Health
Date of Last Physical Exam: Purpose:
Physical Exam Location: Physical Exam Physician:

History

Have you filed charges or complaints with the POEA or NLRC, against your recruiter, or local/overseas employer?:
Yes No
Nature of complaint or case:
Referral
How did you find out about InterStaff?: If other, specify:

I understand and agree that should I fail to meet the Company's physical test in the Philippines and at the job site (aboard), or if for any reason, it is determined that I may not be employed , the Company shall not be liable for loss or damage because of failure or refusal to employ me. Further, I certify that all statements I have made in this application are true and that any misrepresentation or deliberate omission of facts is sufficient ground for cancellation of my application and immediate dismissal should overseas employment materialize. I understand that should this application be denied, Interstaff Inc. has no obligation to furnish reason's) for the rejection.



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