NURSE CANDIDATE BIOGRAPHICAL DATA SHEET FOR EMPLOYMENT IN USA

PERSONAL INFORMATION

DATED:

First Name:  Last Name:  Middle Name: Gender: Female Male

Marital Status: Single Married Divorced Widow Seperated   Date Of Birth:  Place Of Birth:  Religion:

Current Address: City:  State:  Zip Code:  Country:

Permanent Address: City:  State:  Zip Code:  Country:

Telephone Nos. with City/Country Code:         

Web Site:    E-Mail Address:

Nationality:         Passport No:        Date Passport Expires:

Father's Name:  Father's Date of Birth:  Father's Occupation:

Mother's Name: Mother's Date of Birth:  Mother's Occupation:

Spouse's Name:  Spouse's Date of Birth:  Spouse's Occupation:

Child's Name:    Date of Birth:      Name:    Date of Birth:

Child's Name:    Date of Birth:      Name:  Date of Birth:

Child's Name:    Date of Birth:      Name:  Date of Birth:

EDUCATIONAL BACK GROUND

High School: Location: Year: Course: Graduated: No Yes

College: Location: Year: Course: Graduated: No Yes

University: Location: Year: Course: Graduated: No Yes

Other: Location: Year: Course: Graduated: No Yes

Other: Location: Year: Course: Graduated: No Yes

Other: Location: Year: Course: Graduated: No Yes

SEMINARS AND TRAINING

PLEASE LIST BELOW ALL SEMINARS AND TRAINING WORKSHOPS YOU HAVE ATTENDED TO DATE:

Description: Year: Place: For How Long?

Description: Year: Place: For How Long?

Description: Year: Place: For How Long?

Description: Year: Place: For How Long?

Description: Year: Place: For How Long?

Description: Year: Place: For How Long?

PROFESSIONAL EXPERIENCE

PLEASE INDICATE EMPLOYMENT DETAILS BEGINNING WITH YOUR MOST RECENT EMPLOYMENT:

AREAS OF EXPERTISE AND SKILLS

PLEASE TICK MARK/CHECK ALL YOUR CLINICAL SKILLS/AREAS OF EXPERTISE BELOW WITH THE CORRESPONDING YEARS OF EXPERIENCE IN THAT FIELD:

BURNS                               YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11        PSYCHIATRIC                           YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11

CARDIOLOGY                     YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11        PUBLIC HEALTH                       YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11

CATH LAB                          YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11         RECOVERY ROOM                  YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11

CCRN/CCU                         YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11         REHABILITATION                     YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11

CVICCU                              YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11         RENAL                                    YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11

CVOR                                  YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11        RESPIRATORY                         YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11

EENT                                  YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11         SEXUAL ASSAULT                    YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11

ER/TRAUMA                       YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11         SURGERY/SURG. SERVICES   YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11

GASTRO-INTESTINAL         YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11          THORACIC                               YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11

HEM DIALYSIS                   YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11          TRANSPLANT                          YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11

ICU                                     YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11          UROLOGY                               YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11

LABOR & DELIVERY          YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11           VASCULAR                             YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11

LEARNING DISABILITIES    YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11           MEDS/SURG                           YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11

MICU                                  YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11           NEUROLOGY                          YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11

NICU                                  YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11          NURSERY & NEONATAL          YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11

OB/GYN                             YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11          OCCUPATIONAL HEALTH        YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11

ONCOLOGY                       YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11           OUTPATIENT CLINIC               YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11

ORTHOPEDICS                  YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11           PEDIATRICS                           YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11

PACU                                YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11           PICU                                       YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11

CHILD ABUSE                    YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11           OR                                         YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11

    YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11                    YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11

    YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11                    YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11

    YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11                    YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11

    YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11                    YRS: 0 1 2 3 4 5 6 7 8 9 MON: 0 1 2 3 4 5 6 7 8 9 10 11

PLEASE INDICATE YOUR KNOWLEDGE OF OTHER OFFICE OPERATIONAL SKILLS:

BASIC COMPUTER OPERATIONS: None Excellent Good Fair Poor    MICRO SOFT WORD: None Excellent Good Fair Poor      MICRO SOFT EXCEL: None Excellent Good Fair Poor

OTHER:   Excellent Good Fair Poor None  OTHER:    Excellent Good Fair Poor None  OTHER:   Excellent Good Fair Poor None

PLEASE DESCRIBE ABOUT YOUR KNOWLEDGE OF DIFFERENT LANGUAGES:

ENGLISH ORAL: None Poor Fair Good Excellent   READ & WRITE: None Poor Fair Good Excellent     SPANISH ORAL: None Poor Fair Good Excellent   READ & WRITE: None Poor Fair Good Excellent

FRENCH ORAL: None Poor Fair Good Excellent   READ & WRITE: None Poor Fair Good Excellent     GERMAN ORAL: None Poor Fair Good Excellent   READ & WRITE: None Poor Fair Good Excellent

ARABIC ORAL:  None Poor Fair Good Excellent   READ & WRITE: None Poor Fair Good Excellent       OTHER ORAL: None Poor Fair Good Excellent  READ & WRITE: None Poor Fair Good Excellent

OTHER ORAL:   None Poor Fair Good Excellent   READ & WRITE: None Poor Fair Good Excellent       OTHER ORAL: None Poor Fair Good Excellent  READ & WRITE: None Poor Fair Good Excellent

PROFESSIONAL CERTIFICATIONS

PLEASE INDICATE, WHAT EXAMS YOU HAVE TAKEN TO DATE:

                                        PASSED?   SCORES/RATING    LICENSE NO.    NO. OF TAKES   GIVE REASON IF FAILED

RN LICENSURE EXAM:  No Yes                                   

CGFNS:                        No Yes                                    

NCLEX:                         No Yes                                    

TOEFL:                         No Yes                                    

TSE:                             No Yes                                    

TWE:                            No Yes                                    

        No Yes                                    

HAVE YOU TAKEN ANY REVIEW COURSES FOR THE FOLLOWING:

                                     PASSED?    NO. OF TAKES        FEES PAID BY                            NAME OF THE CENTER

RN LICENSURE EXAM:  No Yes                               

CGFNS:                        No Yes                               

NCLEX:                         No Yes                               

TOEFL:                         No Yes                               

TSE:                             No Yes                               

TWE:                            No Yes                               

        No Yes                               

TRAVEL OVERSEAS

PLEASE LIST DOWN ALL THE OVERSEAS TRAVELS THAT YOU HAVE DONE TO DATE.   

DO YOU HAVE ANY RELATIVES IN USA?    NO YES     IF YOUR ANSWER IS YES, THEN PLEASE FILL OUT THE FOLLOWING:

OTHER GENERAL QUESTIONNAIRES:

WILL YOU BRING YOUR FAMILY TO USA?              NO YES                       IF YES, WHEN:   

DO YOU HAVE PENDING PETITION/S IN USA?        NO YES   IF YES, TYPE OF PETITION/S:

WHO SPONSORED YOUR PETITION?                          

DO YOU HAVE ANY PENDING JOB APPLICATIONS IN OVERSEAS?  NO YES IF YES, WHERE?

WHAT IS THE CURRENT STATUS OF APPLICATION?   

DO YOU HAVE ANY PENDING JOB COMMITMENTS?  NO YES   IF YES,  TYPE OF COMMITMENT?

WHICH COMPANY YOU HAVE COMMITMENT FROM?  

DO YOU HAVE ANY PENDING OFFERS OVERSEAS? NO YES                      IF YES, WHERE? 

WHICH COMPANY YOU HAVE OFFERS FROM?          

WHAT ARE YOUR SHORT TERM PLANS? (1-2Years)   

WHAT ARE YOUR MEDIUM TERM PLANS?(3-5Years)  

WHAT ARE YOUR LONG TERM PLANS?(6+Years)       

DO YOU HAVE ANY OF THE RESTRICTIONS ON ANY OF THE FOLLOWINGS:

1. TAKING A REVIEW EXAM THAT WOULD REQUIRE YOU TO DEDICATE AT LEAST 30-90 DAYS.   NO YES

    IF YES, PLEASE STATE REASON.   

2. ACCEPTING A JOB IN USA?     NO YES        PLEASE STATE REASON.

3. RESIGNING FROM YOUR PRESENT EMPLOYMENT IF ACCEPTED BY A HOSPITAL IN USA?      NO YES

    IF YES, PLEASE STATE REASON.   

4. WITHDRAWING YOUR APPLICATION FROM OTHER COMPANY AND TRANSFERRING TO US.     NO YES

    IF YES, PLEASE STATE REASON.   

5. ANY OTHER RESTRICTIONS?           NO YES      REASON.

WHEN WAS YOUR LAST MEDICAL EXAMINATION DONE?         WERE YOU MEDICALLY:   FIT UNFIT

IF UNFIT, PLEASE INDICATE THE REASON:                        

WHAT WAS THE PURPOSE OF YOUR MEDICAL EXAM?     

LIST HERE ANY MEDICAL CONDITIONS YOU HAVE?          

WHERE DID YOU HEAR ABOUT US

WHERE DID YOU HEAR ABOUT US:    --------------------------------- Our Agent Live Seminar T.V. Ads Magazines Newspapers Direct Mail From a Hospital Management From A Friend    NAME OF THE SOURCE:  

IF YOU ARE REFERRED BY ONE OF OUR AGENT, PLEASE INDICATE BELOW ABOUT OUR AGENT'S

PERFORMANCE. THIS WILL HELP US  TO SERVE YOU BETTER.

NAME OF AGENT, REFERRED BY:   AGENT'S ID: AGENT'S COUNTRY:

PROGRAM KNOWLEDGE:  Excellent Good Fair Poor    PERSONAL CONDUCT: Excellent Good Fair Poor       PERSONAL BEHAVIOR:  Excellent Good Fair Poor

TIMELY TASKS:                 Excellent Good Fair Poor         COMMUNICATIONS: Excellent Good Fair Poor  OVER ALL PERFORMANCE Excellent Good Fair Poor

WE APPRECIATE YOUR PATIENTS AND THANK TO ALL OF OUR APPLICANTS FOR SHOWING THEIR INTEREST IN FILLING THIS LONG APPLICATION. AFTER REVIEWING YOUR APPLICATION, WE WILL CONTACT YOU AND LET YOU KNOW AND WILL GUIDE YOU STEP BY STEP FROM THERE.

GOOD LUCK

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