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361950-41719500Nurse Refresher Course ApplicationComplete and save as a Word Doc. Email to Betty Blackman at:hsws@ or fax to 865-674-5324.Once the application is received and reviewed you will be contacted and develop your course. Name: Requesting to attend: _____Onsite course _______ Online_________ Hybrid_________Address: Preferred phone: Alternate phone: Email address: ___ I have not had an active RN license since _______________________ ___ Other Explain: Are you a U. S. citizen? Yes ____ No _____ Female_____ Male_____A. Have you ever been convicted, pled guilty or no contest, or received a suspended imposition of sentence for a felony or other criminal offense (excluding minor traffic violations)? Yes ___ No___ B. Is there any pending criminal case against you which would constitute a felony? Yes ___ No ___ C. Have you been treated for abuse or misuse of any alcohol or chemical substance to the extent that your ability to practice as a nurse would be impaired? Yes ___ No ___ D. Have you experienced a physical, emotional, or mental condition that has endangered the health or safety of persons entrusted in your care? Yes ___ No ___Please give a brief overview of your nursing career, including why you left the workforce and why you wish to return at this time and what you expect from the course: You may attach your resume for further details.YOUR APPLICATION will be completed when all information is received. ?Course applicationBackground checkCurrent Provider Basic Life Support training or complete with basic courseCost of the course is determined after individual program development and a non-refundable fee of 50.00 should be paid to process the application. The total fee should be paid on or before your first day of program.I give permission to have a background check. Yes____ No____ I certify that the answers I have given to each of the foregoing questions are true to the best of my knowledge. Signature of Applicant: ________________________________ Date _____________________ ................
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