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		Pediatric Nursing Positions Application Form Please fill out the following form if you are interested in employment in the nursing field. Position Desired: Shift: <Select One> Days Evenings Nights Region of U.S. I would like: Type of Facility I would like: <Select One> Children's Hospital Pediatrics Unit Other If Other: I would like to work in this specific facility: Job Title: First Name: Middle Initial: Last Name: Home Address: City: State: <Select One> Alberta Alaska Alabama Arkansas Arizona British Columbia California Colorado Connecticut DC Delaware Florida Georgia Guam Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Manitoba Maryland Maine Michigan Minnesota Missouri Mississippi Montana New Brunswick North Carolina North Dakota Nebraska Newfoundland New Hampshire New Jersey New Mexico Nova Scotia Nevada New York Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island South Carolina South Dakota Saskatchewan Tennessee Texas Utah Virginia Virgin Islands Vermont Washington Wisconsin West Virginia Wyoming Yukon Territory Other ZIPcode: E-Mail: Home Phone: Any licenses? Basic Level of Education: <Select One> CNA LPN Diploma ADN BSN School of Nursing: Location: I have been certified as a... Nurse Practitioner. By Whom? Clinical Nurse Specialist. By Whom? Do you have an independent practice? Yes  No Education beyond Basic Program: Additional Certifications: Have you had a course in Pharmacology? Yes No If yes, date: Nursing Experience: Please overwrite this note and indicate the name(s) of hospital(s) and number of beds, or the agency, city, state, positon and length in position. If none, please indicate that. Have you previously completed a PBDS assessment? Yes  No If yes, where?  and when? I have experience in: Yes No Length Status Ambulatory Care Setting yr. <Select One> RN LPN Student NA Cardiology - Medical/Surgical yr. <Select One> RN LPN Student NA Critical Care yr. <Select One> RN LPN Student NA Dialysis - Acute/Chronic yr. <Select One> RN LPN Student NA Emergency Department yr. <Select One> RN LPN Student NA Geriatrics yr. <Select One> RN LPN Student NA Home Health yr. <Select One> RN LPN Student NA Labor & Delivery yr. <Select One> RN LPN Student NA Medical yr. <Select One> RN LPN Student NA Mental Health yr. <Select One> RN LPN Student NA Nursery Level I, II, 111 yr. <Select One> RN LPN Student NA Obstetrics yr. <Select One> RN LPN Student NA P.A.C.U. yr. <Select One> RN LPN Student NA Pediatrics yr. <Select One> RN LPN Student NA Rehabilitation yr. <Select One> RN LPN Student NA Skilled Nursing Facility yr. <Select One> RN LPN Student NA Surgery - Inpatient/Outpatient yr. <Select One> RN LPN Student NA Surgical yr. <Select One> RN LPN Student NA Telemetry yr. <Select One> RN LPN Student NA Press the Submit Button ONLY Once

Ronald A. Christensen, M.D., Medical Advisor
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