Nursing Home Application Form

Do you want to reside in a nursing home? Fill out this application form.

Questions for Nursing Home Application Form

1.

Name

The answer should be a text input.
2.

Gender

The answer should be a single choice:
  1. Male
  2. Female
3.

Date of Birth

The answer should be a date input.
4.

Age

The answer should be a single choice:
  1. Under 18
  2. 18-24 years old
  3. 25-34 years old
  4. 35-44 years old
  5. 45-54 years old
  6. Over 55
5.

Address

The answer should be a text input.
6.

City

The answer should be a text input.
7.

State

The answer should be a text input.
8.

Country

The answer should be a country.
9.

Zipcode

The answer should be a number input.
10.

Marital status

The answer should be a single choice:
  1. Single
  2. Married
  3. Divorced
  4. Separated
  5. Widowed
11.

Do you have working experince at Nursing Home or Adult Care Facility

The answer should be a single choice:
  1. Yes
  2. No
12.

Mention the experience in months

The answer should be a text input.
13.

Medical Insurance Number

The answer should be a number input.
14.

Mention you specialization area 

The answer should be a multiple choice:
  1. Learning disabilities
  2. Marie Curie
  3. Mental Health
  4. Midwifery
  5. Occupational Health
  6. Ophthalmic
  7. ICU
  8. Social Work
  9. Tropical disease
  10. STDs
15.

Upload your resume

File needs to be uploaded.
16.

Signature

The answer should be a text input.
17.

Date of Application

The answer should be a date input.

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