This form (page 5, table 1-1) is used to help determine whether you are eligible for nontaxable travel benefits. It should be filled out prior to starting an assignment, whenever there is a change in your tax home status, or each time you execute a new Professional Services Agreement.
Employee Applicant Statement
I certify that the information provided by me in this application is true and complete to the best of my knowledge. I understand that if I am employed, any false statements or omissions can lead to immediate dismissal, and I agree that Nurses PRN shall not be held liable in any respect if my employment is terminated for that reason. Nurses PRN is hereby authorized to verify the information I have supplied and to conduct any investigation of my personal history records. I authorize the companies, schools, and persons named in this application to give any information requested regarding my employment, character, and qualifications, and release and hold harmless Nurses PRN and the companies, schools, and persons from any liability. I understand and agree that if hired, my employment is at-will, for no definite period and may be terminated at any time without prior notice and without cause. I further understand that any offer of employment may be conditioned upon the results of a physical examination, including tests for the use of controlled substances in accordance with applicable laws.
If hired, I agree to abide by all rules and regulations of Nurses PRN, which I understand are subject to change by Nurses PRN at any time for any reason without prior notice.
Nurses PRN is an equal opportunity employer. Nurses PRN considers applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation, or any other legally-protected status. Those applicants requiring reasonable accommodation to the application and/or the interview process should notify Nurses PRN and request such accommodations.
Should an investigation or legal proceeding adversely affect my professional license/certification or ability to perform the functions of the job, I understand that I am obligated to immediately report said occurrence to Nurses PRN’s Chief Nursing Officer at 888-830-8811. Failure to do so will result in disciplinary action up to and including termination.
I represent and warrant that I have read and fully understand the foregoing.