Universal Worker

General Information

Position applying for:

Specialization:

First Name:

M.I. Last Name:

DOB:

Place of Birth:

Sex:

Male

Female

Nationality:

Home Phone:

Cell Phone:

Office Phone:

E-mail address:

Address:

City, State ZIP:

Emergency Contact:

Emergency Phone:

Emergency Contact Address:

Civil Status

Single

Married

Widow

Separated

Current Employment

Are you currently employed in a hospital?:

Yes

Hospital Name:

Hospital Address:

Bed Capacity of the Hospital:

Bed Capacity of the Unit:

Nurse to Patient Ratio:

Hours per Week:

Schedule

Full Time

Part Time

Volunteer

Are you under an existing contract?:

Yes

Time Remaining on Contract:

Are you required to give notice prior to leaving?:

Yes

Qualification

Exam	Exam Date	Rating	Attempts	Issued on	Valid Until
PRC Licensure Exam
CGFNS Exam
NCLEX - RN Exam
TOEFL/TWE/TSE/TOEIC Exam
IELTS Licensure Exam
Visa Screen Certificate

CGFNS/ICHP Username:

CGFNS/ICHP Password:

Education

Education	Month/Year Graduated	Name of School/Address	Degree Received
College or University
Post Graduate
Other Courses

Seminars/Training

Other languages spoken/written:

Employment History

Employer	From	To	Unit Assigned	Time at Position (Yrs./Mos.)	Schedule

Immediate Family

Spouse	DOB

Children	DOB

Review Programs Attended

Program	Date	Duration	Result	Location
CGFNS
NCLEX -RN
IELTS
TOEFL/TWE
TSE
TOEIC

References

Name	Title	Address	Telephone

Visa Information

Passport Number:

Issuing Country:

Date Issued:

Date Expires:

Have you ever been to the United States?:

Yes

Type of US Visa:

Date Visa Issued:

Date Visa Expires:

Are you presently, or have you previously been sponsored for an immigrant visa, or working visa in the U.S.?:

Yes

If Yes, Case Numbers

Additional information

Memberships and Affiliations

Summary of Experience and Qualifications

Health

Date of Last Physical Exam:

Purpose:

Physical Exam Location:

Physical Exam Physician:

History

Have you filed charges or complaints with the POEA or NLRC, against your recruiter, or local/overseas employer?:

Yes

Nature of complaint or case:

Referral

How did you find out about Universal Worker?:

If other, specify:

I understand and agree that should I fail to meet the Company's physical test in the Philippines and at the job site (aboard), or if for any reason, it is determined that I may not be employed , the Company shall not be liable for loss or damage because of failure or refusal to employ me. Further, I certify that all statements I have made in this application are true and that any misrepresentation or deliberate omission of facts is sufficient ground for cancellation of my application and immediate dismissal should overseas employment materialize. I understand that should this application be denied, Universal Worker, Inc. has no obligation to furnish reason's) for the rejection.