MHS, Ltd., 43 Elizabeth Ave., P.O. Box CB-13022, Nassau, Bahamas
Nurse Application Form
Please fill in your name (with your full middle name - the insurance company requires it):
address:
city: state/province: zip/postal code:
country:
country of birth country of citizenship date of birth
home phone home fax E-mail address
work phone work fax
current employer name
address
phone supervisor
Education:
undergraduate school year graduated degree
nursing school year graduated degree
postgraduate training
please list all states and countries in which you have or have had a nursing license and your license number in each
Have you had experience in shipboard medicine? Tell us about it (dates, ships, etc.)
What languages other than English do you speak?
Please list all previous employers for the last 10 years: names, addresses, dates
Please list any professional organizations you belong to.
What was the date of your last ACLS course or recertification?
ATLS?
Have your clinical privileges at any hospital ever been suspended, diminished, or revoked?
Have you ever been disciplined or reprimanded at any hospital or medical institution?
Have you ever had any professional or medical license suspended, limited, or revoked by any state board or licensing agency?
Do you have any physical impairment which might limit your ability to practice nursing?
Have you ever had or been treated for alcohol or drug dependency?
Have judgements or settlements been made against you in any professional liability case or are there any claims pending?
If the answer to any of the above questions is ``yes", then please tell us the details:
Do you have any physical disabilities of hearing?
of sight?
of movement?
What was the date of your most recent chest X-ray?
of your most recent TB skin test?
Please give the names, addresses, and phone numbers of three references who are familiar with your current practice.
Do you have health insurance that would cover you while working outside your native country?
Do you own or have experience with computers? If so, what programs are you proficient with?
What size T-shirt do you wear?
Which dates on which ship would you like to work? (See the schedule page for availability)
By submitting this application the applicant hereby attests to the truthfulness of all information given above and gives MMS, Ltd. and MHS, Ltd. and their agents and employees permission to contact any of the sources given above to verify such information and gives any of the sources listed above permission to release such information.