Corporate Offices
1806 South Alpine Suite D
Rockford IL 61108
Phone(815) 226-0286
Fax(815) 226-8587
Step 1 of 4

* are requred fields
Application For Employment
* * * *
Last First Middle Social Security #

Current Address * *
  No. Street Apt #

* * * *
City County State Zip

*How long have you lived at this address? / (years/months)
If less then 5 years, please provide us with your previous address?
Previous Address
  No. Street Apt #

City County State Zip

*Home Telephone No. () Alternate No. ()
*Emergency Contact *Phone ()

*Are you 18 years of age or older?

Yes No

*If hired, can you provide proof of legal age? Yes No
*Have you ever worked or attended school under another name? Yes No
(Required for verifying education, employment records and reference)
If Yes, Name:

*Do you have a current Driver's License? Yes No
*If yes, what state was it issued? License #:
*Do you have reliable transportation? Yes No

*Position Applying For *Hourly or annual salary requirement $

*Are you available for work

Full Time Part Time

*Date Available //

*Have you previously filled an application with us? Yes No If yes when?

List relatives working with the Super Nurs Company:
Name: Relationship
Name Relationship
Name of source:

*In the last seven years have you ever been convicted of a felony, misdemeanor or any offense other than a minor traffic offense? Yes No
If yes, please explain:
Note: an answer of "yes" will not disqualify any applicant for consideration for a job; rather, such information is only relevant to the job application process in terms of whether or not the conviction(s) has a direct relationship to the job for which you are applying and whether it would pose an unreasonable risk to property, safety, employees or clients.

*Have you ever committed an offense involving dishonesty or a breach of trust or fraud? Yes No
If yes, please explain: