Worker Registration
Personal Info
User Type
Administrator
Worker
Scheduler
Agency
Customer Service
Marketer
Physician
Family Member
Status
Active
Candidate
Inactive
Applicant
On_Hold
Unhirable
Uninterested
First Name
*
Middle name
Last Name
*
Gender
Not Set
Male
Female
Title
Date of Birth
MM / DD / YYYY
Create Web User
User Id
*
Password
*
Create IVR/Mobile User
User Number
Pin
Pay Code
Not Set
Pay Code 24
Not Set
Pay Rate (per hour)
Pay Rate 24 (per hour)
Quick Books Id
Is Vendor
Item Id
Item Rate
Emerg. Contact
Relationship
Not Set
Emerg.Phone
Addresses
USA
Canada
Mexico
Australia
Alaska
Alabama
Arkansas
Arizona
California
Canada
Colorado
Connecticut
District of Columbia
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
-- Select State --
Home
Work
Mailing
Emails
Work
Personal
Phones
Home
Office
Fax
Direct
Cell
Hospital
Main
Seasonal
TTY
Other
Pager
NumberToCall
Additional Info
What days and hours are you available to work?
How did you hear about ?
Referred by:
Refer a friend
Word of Mouth
Craigslist
Nursing School
Saw Flyer
Newspaper article
Employee fair
Listings
Job Centers
Schools
COA
Company closing
Yellow Pages
Unknown
Do you have a valid driver's license?
No
Yes
Have you ever been convicted of a crime/felony?
No
Yes
Highest Level of Education Completed
School Name
School State or Country
Type Of Degree
Work experience
Company
Years
Dates
Reference Name
Ok To Contact
Yes
No
Notes