Nurse Practitioner Residency Application

Please review the job description here prior to applying.

Personal Information

First Name

Last Name

Mailing Address

Country

Street

City

Region

Postal Code

Phone Number

Email Address

You must have graduated from an accredited Nurse Practitioner Program within 18 months prior to starting the Residency to be eligible for this program.

What date was your degree conferred, as listed on your transcript (MM/dd/yyyy)?

Did you graduate or will you graduate with a Master's degree or higher as a Family Nurse Practitioner or Adult Gerontology Primary Care Nurse Practitioner?

Yes

No

Do you hold a current unencumbered Alabama registered nurse license or multistate nursing license?

Yes

No

Are you a citizen of the United States?

Yes

No

Thank you for your interest in Samford University's Nurse Practitioner Residency program. Your answer indicates that you are not eligible for this residency. If you have questions regarding this, please contact Ms. Carrie Peters at cpeters3@samford.edu.

Are you a current or previous Samford student?

Yes

No

Please provide your SUID.

Samford University is a religious educational institution. Samford’s goal is to accept applicants who have appropriate knowledge, skills and abilities and who possess a strong Christian commitment.
Would you say you have a strong Christian commitment?

Yes

No

If not, do you understand the special Christian commitment of the University?

Yes

No

If yes, please explain why:

Have you reviewed the job description for the Nurse Practitioner Residency?

Yes

No

Are you able to perform the job functions with or without reasonable accommodation?

Yes

No

If offered a position in the residency, when would you be available to begin? (MM/dd/yyyy)

Are you planning to pursue further academic studies?

Yes

No

Education

Please list your most recent education first.

School Name

City & State

Did you graduate?

Yes

No

What degree did you receive?

Major / Minor

Do you have additional education to report?

Yes

No

School Name

City & State

Did you graduate?

Yes

No

What degree did you receive?

Major / Minor

Do you have additional education to report?

Yes

No

School Name

City & State

Did you graduate?

Yes

No

What degree did you receive?

Major / Minor

Work Experience

Please list your current or most recent experience first.

Employer Name

Address

Country

Street

City

Region

Postal Code

Position Title

Start Date of Employment

End Date of Employment

Hours worked per week

Duties

Reason for Leaving

May we contact this employer?

Yes

No

Do you have additional work experience to report?

Yes

No

Employer Name

Address

Country

Street

City

Region

Postal Code

Position Title

Start Date of Employment

End Date of Employment

Hours worked per week

Duties

Reason for Leaving

May we contact this employer?

Yes

No

Do you have additional work experience to report?

Yes

No

Employer Name

Address

Country

Street

City

Region

Postal Code

Position Title

Start Date of Employment

End Date of Employment

Hours worked per week

Duties

Reason for Leaving

May we contact this employer?

Yes

No

License and Certification Information

Type of license or certification

Issuing agency / organization

Date Issued

Expiration Date

Number

Do you have an additional license or certification to report?

Yes

No

Type of license or certification

Issuing agency / organization

Date Issued

Expiration Date

Number

Do you have an additional license or certification to report?

Yes

No

Type of license or certification

Issuing agency / organization

Date Issued

Expiration Date

Number

Skills

Please list any skills or training applicable to this position (example: bilingual, charting software):

References

Name

Title / Position

Company

Phone Number

Email

Reference Type

Personal

Professional

Name

Title / Position

Company

Phone Number

Email

Reference Type

Personal

Professional

Name

Title / Position

Company

Phone Number

Email

Reference Type

Personal

Professional

Supporting Documentation

Please upload your resume / CV and any other additional supporting documents.

How did you learn about this residency?

By clicking "Accept" and by submitting this form, I hereby certify that every statement I have made in this application is true and complete to the best of my knowledge. I understand that any false or incomplete answer may be grounds for removal from consideration or for dismissal after I begin work. I understand that I will have to produce documentation verifying identity and employment eligibility in the U.S. I understand that I may be required to verify any and all information given on this application. I understand that this completed application is the property of Samford University and will not be returned. I understand Samford University may contact prior employers and other references.

Accept

Signature