RN Application

1Section I – Personal Information

2Section II – Education

3Section III – Licensure & certifications

4Section IV – Employment history

5Section V – Experience & skills

6Section VI – Faith & mission alignment

7Section VII – Background & references

Full Legal Name

Preferred Name

Address

Street Address City State ZIP

Primary Phone

Secondary Phone

Are you over the age of 21 years old?

Yes

Are you legally authorized to work in the U.S?

Yes

Have you ever been an employee or volunteer at Shiloh Center?

Yes

Provide the dates and the scope of work done:

Have you ever been convicted of a misdemeanor or felony?

Yes

Please explain:

Have you ever been convicted of violating a law enacted to protect children?

Yes

Please explain:

Position Applying For:

Registered Nurse

Nurse Manager

Sonographer

Other

Type Position Applying For:

Desired Status

Full-Time

Part-Time

PRN

Contract

Date Available to Start:

DD slash MM slash YYYY

How did you hear about Shiloh/Clara Women’s Center?

Highest Form of Education?

Less than High School

High School Diploma or GED

Some College

Associates Degree

Bachelors Degree

Masters Degree

Doctoral Degree

If you attended college, please list the schools you attended:

Degree Earned:

Additional Clinical Training:

Relevant Continuing Education:

RN License Number:

State of Licensure:

Expiration Date:

DD slash MM slash YYYY

Is your license currently active and in good standing?

Yes

Have you ever had disciplinary action taken against your license?

Yes

Please explain:

Additional Certifications (Check all that apply):

BLS

ACLS

NRP

Limited OB Ultrasound Certification

Childbirth Educator/Doula

Phlebotomy

Other

Other Additional Certifications

Current or Most Recent Employer:

Start Date:

DD slash MM slash YYYY

End Date:

DD slash MM slash YYYY

Position/Title:

Supervisor Name & Contact:

May we contact?

Yes

Primary Responsibilities:

Reason for Leaving:

Previous Employer #1:

Start Date:

DD slash MM slash YYYY

End Date:

DD slash MM slash YYYY

Position/Title:

Supervisor Name & Contact:

May we contact?

Yes

Primary Responsibilities:

Reason for Leaving:

Previous Employer #2:

Start Date:

DD slash MM slash YYYY

End Date:

DD slash MM slash YYYY

Position/Title:

Supervisor Name & Contact:

May we contact?

Yes

Primary Responsibilities:

Reason for Leaving:

Previous Employer #3:

Start Date:

DD slash MM slash YYYY

End Date:

DD slash MM slash YYYY

Position/Title:

Supervisor Name & Contact:

May we contact?

Yes

Primary Responsibilities:

Reason for Leaving:

Do you have any specialized skills that would support our mission:

Other Relevant Experience (Nonprofit, Ministry, Education, Counseling, etc.)

Language(s) Spoken

Shiloh and Clara Women’s Center are Christ-centered ministries. We serve clients of all backgrounds with grace and compassion. Your answers help us understand how you will support that environment.

Do you regularly attend church?

Yes

What is the name of your church?

Pastor’s Name?

Briefly share how and when you came to a saving knowledge of Jesus Christ and describe your current relationship with him.

How has God led you to serve in this area of ministry?

What are your views on abortion?

Have you had any personal experiences, yourself or someone close to you, involving an unplanned pregnancy?

Yes

Please explain how this has impacted you.

By entering the information below, you give Shiloh permission to contact your references on your behalf.

Professional Reference #1 (Name/Relationship/Phone/Email)

Personal Reference #2 (Name/Relationship/Phone/Email)

Communication Preferences

Text

Phone

Best Time/Method To Reach You

A background check may be required for specific staff or volunteer roles.

I attest that the information I have provided is true and accurate to the best of my knowledge.