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Name*

Current Address*

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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

Max. file size: 256 MB.

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 Select files

Max. file size: 256 MB.

Are you currently a member of AANA?

Yes

No

AANA Membership

Max. file size: 256 MB.

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!

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