| *First
Name: |
|
| *Last
Name: |
|
| Middle
Initial: |
|
| Current
Address: |
|
| Permanent
Address: |
|
| *Phone
1: |
|
| Phone
2: |
|
| *Email: |
|
| Degree: |
B.Sc. in Nursing |
| |
Diploma in Nursing |
| Have
you spoken with Project Medic before?
|
|
| |
| Please
list your licenses and certifications: |
| |
| License/Certificate
1 |
| License: |
|
| Number: |
|
| Year
Obtained: |
|
| Expires: |
|
| |
| License/Certificate
2 |
| License: |
|
| Number: |
|
| Year
Obtained: |
|
| Expires: |
|
| |
| Please
check areas of specialty (below) |
| |
| |
| Which
VISA qualifying tests have you completed: |
| |
| Please
list your preferred locations: |
| | State
1: |
| | State
2: |
| | State
3: |
| |
| What
is your favorite part of nursing: |
|
|
|
|
|
|
