| Print this form and fax or mail: Fax to: (505) 797-3822 Mail to: 5150 San Francisco RD NE Albuquerque, NM 87109 |
Last Name: __________________________ First Name: __________________________ Middle Initial: __________________________ |
Profession: RN_____ Years Experience LPN _____ Years Experience CNA _____ Years Experience HHA _____ Years Experience |
EXPERIENCE: [Please check all areas in which you have experience.]
ER MED/SURG RR ICU/CCU STEP DOWN TCU REHAB HOME HEALTH L & D POST PARTUM NURSERY PEDIATRICS OR CATH LAB MONITOR TECH PSYCH Other: __________________ Other: __________________ Other: __________________ Other: __________________
PROFESSIONAL LICENSURE:
License #: ___________ State: ____ License #: ___________ State: ____ License #: ___________ State: ____ License #: ___________ State: ____ |
CERTIFICATIONS:
- BLS/CPR - ACLS - NALS - PALS - TNCC - CCRN - Other: __________ - Other: __________ - Other: __________ - Other: __________ |
SPECIALIZED TRAINING:
Have you had a formal critical care course? Yes No Date Completed: __________ Have you had an arrhythmia course? Yes No Date Completed: __________ Are you I.V. certified? Yes No Are you chemotherapy certified? Yes No |
PROFESSIONAL LIABILITY:
Do you carry professional liability insurance? Yes No Pending UNIT OR FLOOR PREFERENCE 1st Choice: __________ 2nd Choice: __________ 3rd Choice: __________ |
CHICKEN POX STATEMENT:
- Yes, I have had chicken pox - No, I have not had chicken pox
Submitted by: ____________________________ Date: __________________
Phone / Email: ____________________________
Reminder: include photocopies of both sides of all professional licenses, registrations, and certifications.
Please complete the Skills Proficiency Checklist to complete your
registration:
Nursing
