Application 1Info2Education3Employment History4References5Licences6Certifications7Confirmation Name First Last Current Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home Telephone NumberWork Telephone NumberCellular Telephone NumberEmail Address Length of Time at above AddressHave you lived at any other addresses in the past 5 years? Yes No Previous Address 1 Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Previous Address 2 Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Position Applied forHow much can you work? Full-time Part-time Per Diem Are you eligible to work in the United States? Yes No Only U.S. citizens or aliens who have a legal right to work in the U.S. are eligible for employment. Can you, upon employment, provide genuine documentation establishing your identity and eligibility to be legally employed in the U.S.? EducationCollege EducationName / LocationNumber of Years CompletedDid you graduate? Yes No Degree / Area of StudyAnesthesia SchoolName / LocationNumber of Years CompletedDid you graduate? Yes No Degree / Area of StudyOther EducationName / LocationNumber of Years CompletedDid you graduate? Yes No Degree / Area of Study Employment HistoryPlease provide the requested information on all employers (including military service) listing your most recent employer first. If this requires more space, please attach on a separate page. Please explain any gaps in your employment history on a separate page. If you have not worked in the past three years, list volunteer work on a separate page.Employer 1Employer NameEmployer AddressStart Date MM slash DD slash YYYY End Date MM slash DD slash YYYY PositionReason for LeavingCompensation RateAdd a Second Employer Yes No Employer 2Employer NameEmployer AddressStart Date MM slash DD slash YYYY End Date MM slash DD slash YYYY PositionReason for LeavingCompensation RateAdd a Third Employer Yes No Employer 3Employer NameEmployer AddressStart Date MM slash DD slash YYYY End Date MM slash DD slash YYYY PositionReason for LeavingCompensation RateHave you ever been convicted of a crime, pled nolo contendere or no contest? Yes No ExplanationPlease explain in detail, listing date, nature of offense and status (attach a separate page if necessary)Is there any criminal action currently pending against you? Yes No ExplanationPlease explain in detail (attach a separate page if necessary).Additional Employment InformationMax. file size: 50 MB. ReferencesNurse Anesthesia of Maine requires three (3) references from anesthesia providers. New graduates please include academic and clinical references.Reference 1Name and TitleHospital / CompanyMailing AddressPhoneEmail PhoneReference 2Name and TitleHospital / CompanyMailing AddressPhoneEmail FaxReference 3Name and TitleHospital / CompanyMailing AddressPhoneEmail Fax Professional Licenses / Certifications / MembershipsRN LicenseState(s) IssuedExpiration DateLicense NumberRN LicenseMax. file size: 50 MB.Do you have a current State of Maine RN License? Yes No State of Maine RN LicenseMax. file size: 50 MB.Other Licenses / Certifications / MembershipsDo you have a current State of Maine Advanced Practice License? Yes No State of Maine Advanced Practice LicenseMax. file size: 50 MB.Are you currently a member of AANA? Yes No AANA MembershipMax. file size: 50 MB.CRNA Certification/RecertificationMax. file size: 50 MB.Date Issued MM slash DD slash YYYY Expiration Date MM slash DD slash YYYY CertificationsAre you BCLS certified? Yes No Expiration Date MM slash DD slash YYYY Copy of BCLS CertificationMax. file size: 50 MB.Are you ACLS Certified? Yes No Expiration Date MM slash DD slash YYYY Copy of ACLS CertificationMax. file size: 50 MB.Are you PALS certified? Yes No Expiration Date MM slash DD slash YYYY Copy of PALS CertificationMax. file size: 50 MB.Do you have any other certifications? Yes No List All Other CertificationsCopies of Each Certicication Drop files here or Select files Max. file size: 50 MB. Have you ever had your RN or APN license revoked? Yes No ExplanationHave you ever voluntarily surrendered your RN or APN license? Yes No ExplanationHave you ever had a professional license revoked or suspended, or have you ever voluntarily surrendered a professional license? Yes No ExplanationHave your hospital credentials ever been suspended or denied? Yes No ExplanationHas your National Certification as a CRNA ever been suspended or denied? Yes No ExplanationHave you ever been on inactive status as a CRNA? Yes No ExplanationHave you ever received notice of a claim or been a defendant in a medical malpractice suit arising from or in connection with your individual professional services? Yes No ExplanationAre you aware of any potential claim arising from or in connection with your individual professional services? Yes No ExplanationDo you have a current, valid Driver’s License? Yes No State IssuedLicense #Please list any moving motor vehicle violations for the past five (5) years:Please list any awards, special distinctions, memberships in professional organizations, papers submitted for publication, etc. ConfirmationPlease Read the Following Statement Carefully Before Signing I certify that the facts set forth in my application for employment with Nurse Anesthesia of Maine are true and complete. I understand that, if employed by Nurse Anesthesia of Maine, any erroneous, false or misleading statements about or omissions of requested information on this application or otherwise provided during the employment application process shall result in my termination of employment. I agree that Nurse Anesthesia of Maine shall not be liable in any respect if my employment is terminated as a result of the falsity of statements, answers, or omissions made by me in this application. I authorize Nurse Anesthesia of Maine and appropriate providers to verify all statements contained in this application, to make any and all necessary reference checks, and to contact any or all of my prior and current employers. I authorize the references and employers listed previously to give Nurse Anesthesia of Maine and appropriate providers any and all information concerning my previous and current employment and any pertinent information they may have, personally or otherwise; and I release all persons, employers, and Nurse Anesthesia of Maine and appropriate providers from liability for any damage or injury that may result from furnishing such information to Nurse Anesthesia of Maine. If employed, I agree to conform to all policies, rules, and procedures of Nurse Anesthesia of Maine. I recognize that employment at Nurse Anesthesia of Maine is at-will, and if employed, such employment can be terminated by Nurse Anesthesia of Maine or me at any time for any or no reason. No person or group of persons other than the President/Chief Executive Officer has the authority to contractually bind Nurse Anesthesia of Maine regarding terms and conditions of employment or to modify the at-will status of all employment at Nurse Anesthesia of Maine. I understand that this application and all attachments are the property of Nurse Anesthesia of MaineApplicants Full NameNOTE: This application will be given every consideration, but its receipt does not imply that the applicant will be employed. This application will remain active for a period of twelve (12) months. If, after such time, you still wish to be considered for employment, then you must re-apply. THANK YOU FOR YOUR INTEREST IN NURSE ANESTHESIA OF MAINE!This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply. Δ
