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Nurse Connection of Wyoming, Inc.
Application for Employment

Personal Information

Name______________________________________________________ Social Security No.__________________________________

Current Address____________________________________ City_______________________ State_________ Zip______________

County__________________________________ Current Phone (____)_____________________________________

Permanent Address___________________________ City______________________ State_______ Zip___________

Permanent Phone_____________________ Cell/Pager__________________________________________________

In case of emergency, please notify____________________________ Phone (____)__________________________

If hired, Can you provide written evidence that you are authorized to work in the U.S.?       ‰ Yes ‰ No

Highest Nursing Degree Earned

ð RN ð BSN ð MSN ð LPN ð CNA ð OTHER

Education Graduated Name/Location of School

Professional Credentials

What is your nursing or medical Specialty?

1._____________________________Years Experience_________ As of (Date)___________________

2. _____________________________Years Experience_________ As of Date)___________________

B. Which of the following credentials do you hold? (Enclose copies)

CPR    Yes No Expiration Date________ PALS    Yes No         Expiration Date_______

ACLS Yes No Expiration Date________ NALS    Yes No         Expiration Date_______

Which of the following certifications do you hold (Enclose Copies)

CNOR Yes No Expiration Date________ CRRN    Yes No       Expiration Date______

CEN      Yes No Expiration Date________ CCRN    Yes No       Expiration Date______

CHEMO Yes No Expiration Date________ OCN     Yes No        Expiration Date______

Critical Care Course Yes No          Expiration Date______________

Other Yes No                              Expiration Date______________

Related Courses/Certification_________________________________ Dates_________________

Professional Organizations __________________________________ Dates_________________

Name of Present or Last Employer_____________________________________________________________________

City/State/Country ___________________________________________________________Phone(____)_____________

Type of Nursing ____________________________Date You Started __________________Date You Left_____________

Reason For Leaving ________________________Starting Salary ________________Ending Salary________________

Immediate Supervisor _________________________________May we contact your supervisor? Yes No

Was this a travel assignment? Yes No If so, with what travel company?_____________________________________

Name of Present or Last Employer______________________________________________________________________

City/State/______________________________________________________________Phone(____)_____ ____________

Type of Nursing ____________________________Date You Started __________________Date You Left______________

Reason For Leaving ________________________Starting Salary ________________Ending Salary_________________

Immediate Supervisor _________________________________May we contact your supervisor? Yes   No

Was this a travel assignment? Yes No If so, with what travel company?_____________________________________

Name of Present or Last Employer______________________________________________________________________

City/State _______________ _______________________________________________Phone(____)_ ________________

Type of Nursing _____________________________Date You Started __________________Date You Left______________

Reason For Leaving ________________________Starting Salary ________________Ending Salary__________________

Immediate Supervisor _________________________________May we contact your supervisor? Yes No

Was this a travel assignment? Yes No If so, with what travel company?______________________________________

Name of Present or Last Employer_______________________________________________________________________

City/State_____________________________ _________________________________Phone(____)__ ________________

Type of Nursing ____________________________Date You Started ___________________Date You Left______________

Reason For Leaving ________________________Starting Salary ________________Ending Salary___________________

Immediate Supervisor ________________________________May we contact your supervisor? Yes No

Was this a travel assignment? Yes No If so, with what travel company?________________________________________

AVAILABILITY

Professional License # _________________________ State__________________ Expires__________________________

Professional License # _________________________ State__________________ Expires__________________________

Professional License # _________________________ State__________________ Expires__________________________

How soon are you available for placement? ________________________________________________________________

Have you been barred from practice of your profession at any time?    Yes No

Are you bondable? Yes No

Has your professional license ever undergone investigation,

Suspension or revocation? Yes No

Have you ever been a defendant in malpractice litigation? Yes No

If you answered "yes" to any of questions 1, 3, or 4, please explain in a separate signed and attached sheet.

PREFERENCES

Nurse Connection of Wyoming, Inc. will attempt to place you in the type of work that interests you the most.
Please provide the information below so that we may find the type of work, location and hours that best suit you.

CLINICAL AREA
PREFER

WILL ACCEPT

GEOGRAPHIC
AREA

PREFER

WILL ACCEPT

WORK
SCHEDULE

PREFER

WILL ACCEPT

SHIFTS

PREFER

WILL ACCEPT

DAYS

12 HOUR

EVENINGS
10 HOUR

NIGHTS

8 HOUR

WEEKENDS

OTHER:

HOLIDAYS

OTHER:

ANY SHIFT

OTHER:

All shifts are filled on a first come, first serve basis. We will try to accommodate each employee as the needs are available.

IMPORTANT: PLEASE READ CAREFULLY AND INITIAL EACH PARAGRAPH BEFORE SIGNING.

As an applicant for employment with Nurse Connection of Wyoming, Inc.:

__________ I understand that this application is not a contract of employment. I understand that Federal law prohibits the employment of unauthorized aliens, and that all persons hired must submit satisfactory proof of employment authorization
and identity. Failure to submit such proof will result in denial of employment.

__________ I understand that Nurse Connection of Wyoming, Inc. will investigate my work history and verify all data given on
this application, on related papers, and in interviews. I authorize all individuals, schools, and firms named herein, except
where noted, to provide any information requested about me, and I release them from all liability for damage in providing
this information.

If hired by Nurse Connection of Wyoming, Inc.:

__________ I agree to abide by the ethics of my profession at all times. If those standards are ever in conflict with the policies and procedures of NCOW, Inc I agree to bring those issues to the attention of NCOW, Inc. and to attempt to gain resolution. I agree, at all times, to hold the needs of patients as the
main consideration.

___________ I understand that Nurse Connection of Wyoming, Inc. follows an "employment at will" policy.
In that I or Nurse Connection of Wyoming, Inc. may terminate my employment at any time or for any reasons consistent with state/federal law.

__________ In accepting employment with NCOW, Inc., I attest that said work in no way interferes with non-compete agreements that may be in place with other employers. I have fully disclosed all existingnon-compete and non-disclosure agreements and have attached pertinent copies hereto.

__________ I understand that I will be acting as an employee of NCOW, Inc. and that all taxes, workers’ compensation and other appropriate deductions shall be made from my compensation as provided by
law. I understand that Workers’ Compensation Insurance is provided by NCOW, Inc. and I will follow all policies and procedures regarding such insurance. I understand that all injuries are to be reported to NCOW, Inc. within seventy-two (72) hours of the injury.

__________ I agree to provided competent and professional care to patients at all times during the
course of my employment. I further agree to : a. abide by all rules and regulations of the facilities
where placed; b.observe all patient and service confidentiality’s; c. to not disclose my rate of pay, compensation remuneration; d. to discuss with NCOW, Inc. only, any problems concerning working conditions at the facilities; e. to not discuss with any other person or company actual or potential
sites or terms of employment that are discussed with me. to not discuss accepting employment
or accept employment with the facility during, and for 180 days following employment with NCOW, Inc.
I understand that I will be held liable for placement fees in the event that these provisions are breached.

_________ I understand that any information contained in my personnel file may be released to
facilities to assist in placement.

My signature here attests that the information provided in this document is true and accurate. I certify that I am qualified, board
certified and/or licensed as represented in this application. I verify that such licenses and certifications are in good standing, or
that I have fully disclosed any investigations, violations, or revocations as an attachment to this application. I agree to provide
written documentation of all degrees, licenses, and certifications listed in this application. I certify, under penalty of fraud and
perjury, that my representations made in this paragraph are absolutely truthful and accurate and further that I have inquired as necessary to insure that the representations made here are current and accurate. Further, I understand that any form of
falsification of this information will be grounds for immediate dismissal, as well as any legal remedies as state or federal
law permits. The terms outlined herein constitute an agreement, by which I agree to abide in the event that I am offered
employment with NCOW, INC.

_______________________________________________________ _________________________________________________________
Applicant Signature                                                                             Date

Nurse Connection of Wyoming, Inc. Checklist
Essential Functions Skills

RNs, LPNs & CNAs

RNs, LPNs and CNAs Complete This Section

This position:

Requires prolonged walking, sitting and standing.

Requires frequent bending, reaching, stooping, pushing, and pulling.

Requires the ability to read, write and communicate in English.

Requires continuous movement throughout the facility. Contact with clients, employees, physicians and visitors.

Requires lifting up to fifty (50) pounds.

Requires good eye/hand coordination, manual dexterity, normal range of vision and normal range of hearing.

Requires understanding of the basis of asepsis and sterile techniques.

Requires knowledge of procedures and techniques in administering simple treatment and related bedside patient care services.

Requires the ability to work as a member of a team.

ALL EMPLOYEES SHALL PRACTICE UNIVERSAL PRECAUTIONS WHEN THE POSSIBILITY OF EXPOSURE TO BLOOD BORNE PATHOGENS EXISTS. A. Whenever there is a possibility of exposure to blood or other bodily fluids routinely recommended precautions
should be followed. The level of intervention should be determined by the degree of potential risk. 1. If there is accidental contact with blood or other bodily fluids, hands should be washed immediately and thoroughly. 2. Particular care should be
taken in emergency situations where the risk is unknown and the possibility of accidental exposure is heightened. B. All disposable sharp items should be placed in puncture-resistant containers located in close proximity to the area in which
they were used. No needles are to be recapped or reused and once used, all needles are to be rendered inoperable. C. In
order to reduce the need for mouth-to-mouth resuscitation there should be appropriate ventilation devices located
whenever the need for resuscitation can be reasonably anticipated. D. It is appropriate to dispose of bodily fluid in the
toilet. Those items that cannot be disposed of in this manner should be wrapped securely in a plastic bag and disposed
of in a manner that is consistent with Federal, State and local regulations. 1. Spills of bodily fluids should be cleaned with an appropriate detergent while the individual is wearing disposable gloves. 2. The affected surface should be disinfected with bleach, sodium hypoclorite, or another EPA approved mycobacterial disinfectant.

I have read and understand the above statements and state that I can perform the essential functions of this job.

____________________________________________________________   _____________________________________________________
Signature                                                                                                         Date

RNs and LPNs ONLY Complete This Section

This position:

Requires knowledge of general nursing theory and practice: biologic, emotional, rehabilitative, physical, social, and medical sciences including their applications.

Requires working knowledge of equipment such as IMEDS, monitors, suction machines, etc.

Requires use of telephone and/or computer.

Requires the ability to read and interpret physician orders.

I have read and understand the items listed above and state that I can perform the essential functions of this job with or without reasonable accommodation.

____________________________________________________________     ____________________________________________________
Signature                                                                                                            Date

Applicant Complete The Following

Release Authorization

In connection with my application for employment, I understand that an investigative consumer report may be requested
that will include information as to my character, work habits, performance, and experience, along with reasons for
termination of past employment. I understand that as directed by company policy and consistent with the job described,
you may be requesting information from public and private sources about my: worker’s compensation injuries, driving
record, court record, education, credentials, and references.

Medical and workers’ compensation information will only be requested incompliance with the Federal Americans with
Disabilities Act (ADA) and/or any other applicable state laws. According to the Fair Credit Reporting Act, I am entitled
to know if employment is denied because of information obtained by my prospective employer from a consumer reporting
agency. If so, I will be notified and given the name and address of the agency or the source which provided the information.

I acknowledge that a telephonic facsimile (FAX) or photographic copy shall be valid as the original. This release is valid
for most federal, state and county agencies.

I hereby authorize, without reservation, any law enforcement agency, institution, information service bureau, school,
employer, reference or insurance company contacted by NCOW, Inc. or its agent, to furnish the information described
in Section I.

The following information is required by law enforcement agencies and other entities for positive identification purposes when
checking public records. It is confidential and will not be used for any other purposes.

____________________________________________ ________________________________________________
Please print your full name Please print other names you have used

_________________________________ _____________   _____________________ ______________________
City                                                             State                  Zip Code                             Social Security Number

_____________________
Date of Birth                                    Male      Female
                                                       Asian Black Hispanic White Other

_______________________________ _____________
Drivers License Number                   State

_____________________________________________
Name as it appears on license

___________________________________ _________
Signature                                                      Date

If Required Subscribed and sworn before me:

Notarize here

__________________________________
Name

__________________________________
Date

__________________________________
Notary Public

__________________________________
My commission expires

Nurse Connection of Wyoming, Inc.
Standards and Conditions of Employment

Employees will conduct themselves in an ethical and professional manner at all times.

Use of foul or inappropriate language will not be tolerated.

Drug use, other than prescription or over-the-counter medications, will be considered basis for termination.

An in-house urine drug screen is mandatory for employment, at the applicant’s expense. Random drug screening may also be performed at the discretion of NCOW, Inc., at the expense of NCOW, Inc.

Employment compensation will be based upon level of education and experience. Compensation rates are confidential and not to be discussed or divulged to other employees, facility employees or other travelers.

Personal calls, while on duty, will not be permitted, unless they are of an emergency nature. Personal calls can be made while on break or lunch. Personal long-distance calls will be at the caller’s expense.

Illness or absences beyond two (2) days will require a doctor’s release in order to return to work.

Medical professionals will be required to wear regular uniforms, preferably scrubs. No street clothes will be allowed at the facilities.

All long hair must be off the neck; a bun, twist, or braid is acceptable. No "flashy" ornaments, bows or flowers are to be worn in the hair. Clips to hold the hair up is permitted. Body piercing is limited to one pair of small in earrings.

Good personal hygiene is required. Untidiness in personal appearance will not be accepted and will be cause to be denied work. Clothing should be clean, ironed and tidy.

All employees must report fifteen (15) minutes prior to start of shift.

Orientation at each facility must be completed before beginning a shift.

An evaluation must be obtained from each facility worked. The evaluations are on your timecard and should be completed and signed by the facility’s charge nurse.

Time sheets are to be turned in every Monday by 5:00 pm. An employee may fax the timecard in but the original must be sent to the office. The timecard must be signed by the charge nurse or floor supervisor. Be sure all information is on the timecard prior to signing. Timecards cannot be altered after they have been signed.

All employees must have at least one (1) contact telephone number (home, message, cell telephone, pager). Personnel not on contract must contact the scheduling office with availability once a week.

Conflicts or problems that arise while on duty at a facility are to be reported directly to NCOW, Inc. and not to the facility (unless it involves a patient).

Should an employee be offered additional shifts at a facility, NCOW, Inc. must be contacted for approval and confirmation of the shift(s).

Nurse Connection of Wyoming, Inc. has a finder’s fee of forty-five hundred dollars ($4,500.00), to be paid to NCOW, Inc. by any employee taking a position at any facility under contract with NCOW, Inc. where the employee is placed, for up to 180 days after termination of employment with NCOW, Inc.

It is the responsibility of each employee to carry sufficient insurance coverage on his/her own vehicles. At no time will NCOW, Inc. be held responsible or liable for any automobile accidents.

Employment with NCOW, Inc. is "at will"; this is not a contract of employment and there is no guarantee of future employment. Employment can be terminated at anytime, with or without cause, with or without notice, by either party.

I have read and understand the above listed conditions, and I agree to abide by all of the statements.

_________________________________________________ ___________________________________
Signature                                                                                 Date

Nurse Connection of Wyoming, Inc.
Physician’s Statement

Patient __________________________

Date of Birth______________________

Social Security #___________________

Procedure Date Result

TB Skin Test                ________ _________

Chest X-Ray (only for Positive

TB test)**                       ________ _________

Hepatitis B Titre           ________ ________

OR

Hepatitis B Vaccine 1 ________ ________

Hepatitis B Vaccine 2 ________ ________

Hepatitis B Vaccine 3 ________ ________

MMR Vaccine               ________ ________

Rubella Titre                 ________ ________

Rubeolla Titre              ________ ________

Tetanus Booster        ________ ________

Physician Signature_______________________________________________________

TB skin test required annually Chest X-Ray required every two years for positive TB results

Hepatitis B Declaration (For no shown record of these vaccinations)

I attest that I have either received the hepatitis B inoculation series and cannot produce the relevant records or that I understand pertinent risks and do not wish to receive that inoculation series.

Employee Signature_______________________________________________________

Date____________________________________________________________________

Nurse Connection of Wyoming, Inc.
Letter of Reference

To:____________________________________________________
        Employer
_______________________________________________________
Address

_______________________________________________________
City                                                                         State                                         Zip Code

Attention:
_______________________________________________________
Supervisor Title

I have made application for employment with Nurse Connection of Wyoming, Inc. I hereby authorize you to furnish information concerning my employment record and ability. I release you from any claims that may arise in relation to your response and the information provided.

____________________________ ___________________ __________________________
Name Used While Employed                                     Position Held                                 Clinical Specialty

Date of Employment from_________________ to __________________________________________

Reason for leaving________________________________________________________________

______________________________ __________________ _________________________
Signature                                                                         Social Security Number             Date

Performance Evaluation

Please Provide the Following Information

Is the information above correct? Yes No        If no, What is incorrect?________________________

                                               Please place a check mark in appropriate box

Exceeded Expectations Met Expectations Did Not Meet Expectations Comments

Punctuality

Charting Skills

Performance

Adaptability

Initiative

Attitude

Appearance

Cooperation

Would you rehire this person? Yes No

Why or Why not? _____________________________________________________

______________________________ __________________________________
Completed By                                                                                     Date



Thank-you for your interest in Nurse Connection of Wyoming, Inc. We are a family owned and operated business that provides staffing assistance to medical facilities throughout Wyoming, Colorado and Nebraska.
We offer our employees the opportunity to work short or long term assignments with the opportunity to explore various areas of expertise.

The Application Packet

These forms are designed to provide us with your education, experience and your
future goals. Please fill out the enclosed forms as completely as possible. Please
leave blank any areas that do not apply to you.

The Skills Checklist(s) – These lists are designed to give you a chance to assess your skills and determine your specialty(ies). Please fill these out as accurately and completely as possible and sign where indicated to validate the assessment.

The Reference – Please fill out the reference form for your last employer. Nurse Connection of Wyoming, Inc. reserves the right to contact all references on an employment application however we will not contact your current employer without your permission.

NCOW, Inc. Standards and Conditions – Prior to your employment, you will
be asked to read and sign off on standards and conditions followed by the
company. You will also be asked to obtain an eight-panel urine drug screen,
at your expense, prior to working any shifts.

When you have completed this application packet please return it to:

Recruiter
Nurse Connection of Wyoming, Inc.
7300 Yellowstone Road
Cheyenne, WY 82009
307-638-9323
888-676-2848 Toll Free
307-778-9474 Fax

Please feel free to call if you have any questions. We look forward to meeting you.

CLINICAL AREA	PREFER	WILL ACCEPT	GEOGRAPHIC AREA	PREFER	WILL ACCEPT

WORK SCHEDULE	PREFER	WILL ACCEPT	SHIFTS	PREFER	WILL ACCEPT
DAYS			12 HOUR
EVENINGS			10 HOUR
NIGHTS			8 HOUR
WEEKENDS			OTHER:
HOLIDAYS			OTHER:
ANY SHIFT			OTHER:

	Exceeded Expectations	Met Expectations	Did Not Meet Expectations	Comments
Punctuality
Charting Skills
Performance
Adaptability
Initiative
Attitude
Appearance
Cooperation