**PLEASE BE SURE TO RETURN THIS FORM ALONG WITH ...
NURSING APPLICATION ADDENDUM
(Must be signed & submitted with application)
|Applicant Name: | |
|Position: | |
|Email Address: | |
Check all boxes that would indicate your Interest and Availability.
I am available to work at the following VA Western New York locations:
Batavia Buffalo Other
I am available to work the following schedules:
| Full-time | 8 hour shift |
| |12 hour shift |
| Part-time (8 hour shift) |16 hours/week |
| |20 hours/week |
| |24 hours/week |
| Part-time (12 hour shift, 24 hours/week) | Intermittent (Per Diem) |
I prefer/will accept positions as indicated below:
|Unit Preference: |Shift Preference: |
|Medical |Permanent Evening |
|Surgical |Day/Evening Rotation |
|Long-Term Care |Permanent Nights |
|Other |Day/Night Rotation |
Please provide the last name(s) that will be on any college transcripts if it differs from the name on your application:
On your application, please be sure to provide telephone numbers for all educational and employment facilities you have listed for verification purposes.
Signature of Applicant Date
................
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