Nightingale Nursing Services - Halifax, Dartmouth and Sydney, Nova Scotia
Position Information
Position Requested:
Registration Number:
 

Personal Information
SIN:

Name:

Address:
City:
Province/State:
Postal Code:
E-mail:
Date of Birth:
MM/DD/YYYY 		   
Next of Kin: Phone number: Eg: (902) 123-4567
 
Phone/Fax numbers
Phone Type: Phone number: Eg: (902) 123-4567
Phone Type: Phone number: Eg: (902) 123-4567
Fax number:
(if applicable)		 Eg: (902) 123-4567  
 
Educational Background
School Attended From Date To Date
1. 
2. 
3. 
 
Job Related Skills
Skill   Year Recertification
CPR
First Aid
Crisis Intervention
Are you bondable?    
Do you have any
back problems/injuries?		    
Comments:
 
Employment History
Name of employer   From Date To Date
1. 
  Reason for Leaving
2. 
  Reason for Leaving
 
Work References
Name   Phone number
1.  Eg: (902) 123-4567  
2.  Eg: (902) 123-4567  
    
Personal References
Name   Phone number
1.  Eg: (902) 123-4567
2.  Eg: (902) 123-4567