RN REFRESHER PROGRAM

This application process is lengthy. You may want to type and save the answers to the questions in a word processing document, then copy and paste the answers into the online form.

Fields with a red asterisk (*) are required information. If a required field is blank, the form will not submit properly.

Personal Information

*First:
Middle:
*Last:

*Address:
*City:
*State:
*Zip Code:
*Phone:
Alternate Phone:
*E-mail Address:

Education Record

*College/University:
*Degree Completed (MM/DD/YEAR):
*Licensure/Certifications:

Please list any additional information such as special skills or training you feel will be helpful to us in considering your application:

References

Please provide three professional references.

References 1
*Name:
*Address:
*City:
*State:
*Zip Code:
*Phone:
E-mail Address:

References 2
*Name:
*Address:
*City:
*State:
*Zip Code:
*Phone:
E-mail Address:

References 3
*Name:
*Address:
*City:
*State:
*Zip Code:
*Phone:
E-mail address:

Employment Record

Please list nursing experience (including hospital, clinic, agency etc.). Begin with your most recent employment.

If you have had more than one employer, please provide additional information in the fields provided.

Employer 1
*Name:
*Address:
*City:
*State:
*Zip Code:
*Job Title/Duties:
*Date Hired (MM/DD/YEAR):
*Date Left (MM/DD/YEAR):
*Reason for Leaving:

Employer 2
Name:
Address:
City:
State:
Zip Code:
Title/Duties:
Date Hired (MM/DD/YEAR):
Date Left (MM/DD/YEAR):
Reason for Leaving:

Employer 3
Name:
Address:
City:
State:
Zip Code:
Job Title/Duties:
Date Hired (MM/DD/YEAR):  Date Left (MM/DD/YEAR):
Reason for Leaving:

Please list all other employment.

Employer 4
Name:
Address:
City:
State:
Zip Code:
Job Title/Duties:
Date Hired (MM/DD/YEAR):
Date Left (MM/DD/YEAR):
Reason for Leaving:

Employer 5
Name:
Address:
City:
State:
Zip Code:
Job Title/Duties:
Date Hired (MM/DD/YEAR):
Date Left (MM/DD/YEAR):
Reason for Leaving:

*Have you ever been known by another name that will enable us to check your work or educational record?   

If yes, please give name:

*Have you worked at WVUH before?

If yes, please give dates and job title:


*Please write a short paragraph describing factors influencing your decision to return to the nursing practice.

Applicant’s Certification

(Please read this statement carefully before signing)

I herby authorize the investigation of all matters contained in this application, including verification of my answers to the above questions.

I understand that references will be sought by WVUH regarding my previous work and educational background.

I understand that my participation in the Program is dependent upon satisfactory completion of a physical examination which will include a drug screening.

I understand my participation in the Program may be dependent upon a satisfactory criminal background check.

I agree that any misleading or false statements may be sufficient cause for WVUH to discontinue its consideration of my application or, should any misleading or false statement be discovered after my selection into the RN Refresher Program, for my immediate dismissal from the Program.

I understand that neither this application nor the granting of an interview for the RN Refresher Program is intended to create or shall create a promise of acceptance into the Program or of any employment with WVUH.

*By checking this box you have created an electronic signature as legally binding as your hand-written signature:

*Date (MM/DD/YEAR):

Please check that all required fields are completed before submitting this form.