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Employment Application

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• Name*
• 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 FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country
• Primary Phone
• Email Address*
• Position Applied For:
  • CRNA Full-Time
  • CRNA Part-Time
  • CRNA Per Diem
  • Administrative Position
• Date Available For Employment
• Referred By: (i.e. Gaswork; friend; Social Media; NAMe employee; etc.
• 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.?

• Education/Employment History

• Upload Current CV here

• Employment History

  Please include on CV all previous employers (including military service) listing your most recent employer first. Please explain any of the following: gaps in your employment history; If you have not worked in the past three years and list any volunteer work.

• References

  Nurse Anesthesia of Maine requires five (5) references from anesthesia providers. New graduates please include academic and clinical references.

• Reference 1

• Name and Title
• Hospital / Company
• Mailing Address
• Phone
• Email
• Fax

• Reference 2

• Name and Title
• Hospital / Company
• Mailing Address
• Phone
• Email
• Fax

• Reference 3

• Name and Title
• Hospital / Company
• Mailing Address
• Phone
• Email
• Fax

• Reference 4

• Name and Title
• Hospital / Company
• Mailing Address
• Phone
• Email
• Fax

• Reference 5

• Name and Title
• Hospital / Company
• Mailing Address
• Phone
• Email
• Fax

• Professional Licenses / Certifications / Memberships

• CRNA Certifications/Recertification/Licenses (i.e. CNA; BLS; ACLS; PALS)
  Drop files here or
• Are you currently a member of AANA?
  • Yes
  • No
• AANA Membership

• Have you ever been convicted of a crime, pled nolo contendere or no contest?
  • Yes
  • No
• Explanation
  Please 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
• Explanation
  Please explain in detail (attach a separate page if necessary).

• Have you ever had your RN or APRN license revoked?
  • Yes
  • No
• Explanation
• Have you ever voluntarily surrendered your RN or APRN license?
  • Yes
  • No
• Explanation
• Have you ever had a professional license revoked or suspended, or have you ever voluntarily surrendered a professional license?
  • Yes
  • No
• Explanation
• Have your hospital credentials ever been suspended or denied?
  • Yes
  • No
• Explanation
• Has your National Certification as a CRNA ever been suspended or denied?
  • Yes
  • No
• Explanation
• Have you ever been on inactive status as a CRNA?
  • Yes
  • No
• Explanation
• Have 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
• Explanation
• Are you aware of any potential claim arising from or in connection with your individual professional services?
  • Yes
  • No
• Explanation
• Do you have a current, valid Driver’s License?
  • Yes
  • No
• State Issued
• License #

• Confirmation

• Please 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 Maine

• Applicants Full Name

• NOTE: 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!