LPN Application Form


Skills and Qualifications


Employment History

Please provide references below if applicable

Educational Background

If job related

Name & Location

Years completed

Did you graduate?

Course of study

I understand that if I am employed, any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate discharge from the employer service, whenever it is discovered.

I give the employer the right to contact and obtain information from all references, employers, educational institutions and to otherwise verify the accuracy of the information contained in this application. I hereby release from liability the employer and it's representatives for seeking, gathering and using such information and all other persons, organizations of corporations for furnishing such information.

The employer does not unlawfully consideration for employment on a basis prohibited by local, state, or federal law.

This application is current for only 60 days. At the conclusion of this time, if I have not heard from the employer and still wish to e considered for employment, it may be necessary to fill out a new application.

If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that two representative of the employer other than an authorized officer, has the authority to make any assurances to the contrary. I further understand that any such assurances must be in writing and signed y an authorize officer.

I understand it is this company's policy not to refuse to hire a qualified individual with a disability because of that person's need for a reasonable accommodation as required by the ADA.

I also understand if I am hired, I will be required to provide proof of identity and legal work authorization.

Independent Contractor Checklist


Alien Card Passport
2 References
Drivers License
Auto Insurance
Social Security
Professional License/Certificate
CPR (Duplex)
Covid-19 Vaccine
Current Physical ( Must be 6 months from date of application)
Current PPD/CXR (Must be 6 months from date of application)


Infection Control
IV Therapy Certificate
HIV/Aids Update
HIV 4 Hour Initial Certificate
Domestic Violence
Medical Errors
Alzheimer’s (4 Hours Initial)
Level 2 Background Screening
Recognizing Impairment
Florida Laws & Rules
Human Trafficking