Phoenix Health Care | New Jersey Placement Agency for Nurses

Please completely fill out the form below. Form fields marked with an asterisk (*) are required. When you have completed your application, click the "Submit" button at the bottom of this page.

If you have any questions about this application or need more information before applying, please feel free to contact a nurse recruiter at our toll-free number or e-mail us at: contactus@phoenixhealthcarenj.com

Thank you for applying to Phoenix!

*First Name:

*Last Name:

*Social Security #:

*Street Address:

*City:

*State:

*Zip:

County:

*Home Phone #:

Work Phone #:

Cell Phone #:

Pager #:

E-Mail:

*NJ RN License #:

Expiration *Date:

*Area of Expertise:

*Hospitals:

*Shift Preference:

*Company:

Expiration *Date:

*Policy #:

Coverage *Limits:

Institution

From/To

Degree or Certificate

*Undergraduate:

Graduate:

College:

(Start with most recent)

Facility:

Address:

From/To:

Unit(s) Worked:

Supervisior:

Phone #:

Facility:

Address:

From/To:

Unit(s) Worked:

Supervisior:

Phone #:

B.C.L.S.:

Expiration Date:

A.C.L.S.:

Expiration Date:

I.V. Certification Date:

Institution:

CCRN Date:

CCRN #:

Expiration Date:

CEN Date:

CEN #:

Expiration Date:

Please check areas in which you are clinically competent and willing to work (must have 1 yr. current experience in the area checked)

Medical ICU	Emergency/ERH	Private Duty
Coronary ICU	PACU	Well Baby
Surgical ICU	L&D/P.P	Supervisor
Open Heart	General Peds	Telemetry
Operating Room	Utilization Review	Sub Acute / LTC
Neonatal ICU	Oncology	Psych
Pediatrics ICU	Med/Surg	Case Management - D/C Planning

Please list pertinent continuing education / critical care courses completed. Include ICU Certification, seminars and in-service programs:

Course:

Date:

Location:

Course:

Date:

Location:

Course:

Date:

Location:

By submitting this form, I certify the above information to be true and accurate.

Phoenix Health Care, Inc.
1-800-464-4481
560 Sylvan Avenue
Englewood Cliffs, NJ 07632