Odh Form 805 - Uniform Employment Application For Nurse Aide Staff
ADVERTISEMENT
1
2
3
4
5
6
7Nurse Aide Registry
1000 N.E. 10
Street
th
Oklahoma City, OK 73126
Tel. (405) 271-4085
Uniform Employment Application for Nurse Aide Staff
This application form is required by Title 63 O.S. Section 1-1950.4 of state law and by the Oklahoma State Board of
Health Rules OAC 310-2-15-3. This uniform application shall be used as the only application for employment of nurse
aides in nursing and specialized nursing facilities, residential care homes, assisted living centers, continuum of care
facilities, hospice programs, adult day care centers and home care agencies on and after January 1, 2001.
This employer does not discriminate in its hiring decisions or in any other employment decision on the basis of race,
color, sex, religion, citizenship, national origin, veteran status, age or upon a physical or mental disability which is
unrelated to the applicant’s/employee’s ability to perform the essential functions of the position.
Date of Application:
Date Available to Start Work:
_________________
_________________
Personal Information
Name: ____________________________________________________________ Social Security Number:_____________________
(Last)
(First)
(Middle)
List any other name(s) you have previously worked under, such as maiden name:_____________________, _____________________
___________________________, __________________________, __________________________, __________________________
Present Address:______________________________________________________________________________________________
(Street)
(City)
(State)
(Zip)
Permanent Address
: _____________________________________________________________________
(if different than present address)
(Street)
(City)
(State)
(Zip)
Telephone Number: ______________ Date of Birth: _______________ Sex: ____ M ____ F Race: ________________________
Emergency Contact Person: _____________________________________________________________________________________
(Name)
(Address)
(Phone Number)
Employment Desired
Position applied for: ____________________________________________________________ Salary required: _________________
Hours available to work: ______ Days ______ Evenings _____ Nights _____Weekends
Will you accept employment of: ______ Full Time? ______ Part Time? _____ Occasional Part Time?
U.S. Military Record
Branch: ____________________ Date Entered: ___________ Date Discharged: ___________ Type of Discharge: _______________
(
Prior Work History
List your last four (4) jobs beginning with your most recent or current employer.)
Employer’s Name:__________________________________________________________ Telephone Number: _________________
Employer’s Address: __________________________________________________________________________________________
(Street)
(City)
(State)
(Zip)
Position Held: ______________________________ Supervisor: _______________________________________________________
Dates Employed: From (month/year) ________________ To (month/year) ________________ Salary: _______________________
Reason for Leaving: ___________________________________________________________________________________________
Oklahoma State Department of Health
1
ODH Form 805
Protective Health Services
Revised 07/08
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal