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Name___________________________________________________________
Address in USA (If any)______________________________________________
Address in Home Country____________________________________________
Phone number________________Marital Status:(M) (S) (D) (Separated)
Check one
Date of Birth____________________ Citizenship________________________
Country where born__________________________
Country studied nursing_______________________
Do you have US. State license? In what state (s)
______________________________
Do you have CGFNS ( )Yes ( ) No Do you have BSN degree ( )Yes ( ) No
Do you have Associate in Nursing diploma from US/Canada? ( ) Yes ( )No
Actual years of experience as RN_________________ Sex ( )Male ( )
Female
Current Nonimmigrant visa___________________________
!-94#______________________ Type of Visa_________________________
Expiration Date of Visa ________________ Date arrived in U.S.A.?______
US. Social Security Number:____________________________________
State your nursing experience beginning from the present (until three years
ago only):
Name of employer:(1)__________________Address_______________________
Duties & responsibilities:_____________________________________________
_________________________________________________________________
Name of employer:(2)____________________Address_____________________
Duties & responsibilities:_____________________________________________
_________________________________________________________________
Name of employer:(3)____________________Address_____________________
Duties & responsibilities:_____________________________________________
________________________________________________________________
Spouse and children's name, date of Birth and present address:______________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Education background: (College only) Name of School and Country____________
_________________________________________________________________
Please email back your answers.
*ACTUAL EMPLOYER
If the Registered Nurse is working in a facility or hospital, it is
acceptable to be petitioned by a different employer. The petitioner may offer you a job in the future
as Registered
Nurse and show ability to pay your salary.
Email:
workandstay@usa.com Fax:
626-447-2191
US Address: P.O. Box 654, Temple City, CA 91780
2/F Manican Building Kamagong corner Baticulin Sts.,
San Antonio Village, Makati City, Philippines 1203
Copyright 2000 TPC
Private Policy
Disclaimer
Contact Us
We require the applicant
to have an email address
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