LPN Application | Sulandra Community Living Services

Basic Information

Step 1

First name

Please enter your first name.

Last name

Please enter your last name.

Email

Please enter a valid email.

Phone

Please enter a valid phone number.

Address

Please enter your address.

Apt / Unit

City

Please enter your city.

State

Please select your state.

ZIP

Please enter a valid ZIP code.

Earliest start date

Please select a start date.

License & Credentials

Step 2

Provide your LPN license details and current certifications.

LPN license number

License number is required.

Issuing state

Issuing state is required.

License expiration date

Expiration date is required.

NPI number (optional)

Current certifications (select all that apply)

BLS (Basic Life Support)

CPR

First Aid

IV Therapy / IV Certification

Other

No current certifications

Please select at least one option (or select “No current certifications”).

Clinical skills / specialties (optional)

Availability & Preferences

Step 3

Employment type

Please select an employment type.

Preferred shift

Please select a shift preference.

Desired hours per week

Reliable transportation?

Days available

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Please select at least one day.

Education

Step 4

School / Program

School/program is required.

Graduation year

Graduation year is required.

Additional education notes (optional)

EHR experience (optional)

Work Experience

Step 5

Add at least one recent job.

Please add at least one complete work experience.

Resume & Documents

Step 6

Resume (PDF, DOC, DOCX)

Click to choose resume… No file

Max 10MB. Required.

Please upload your resume (10MB or less).

Cover letter (optional)

Click to choose cover letter… Optional

Max 10MB.

License / certification documents (optional, multiple)

Click to choose documents… Optional

Max 10MB per file.

Uploads: On submit, all selected files are uploaded to Firebase Storage and saved with your application. The uploaded file links will appear below after submit.

Screening Questions

Step 7

Years of LPN experience

Please select your experience level.

Work authorization (U.S.)

Please select an option.

Can you pass a background check and drug screening?

Yes, I consent to screening.

No.

Please select an option.

Why are you interested in this LPN role? (optional)

Professional References

Step 8

Provide at least two professional references. You may add more.

Please provide at least 2 complete references.

I consent to contact my references.

Consent to contact references is required.

Agreement & Signature

Step 9

I certify that the information provided is true and complete to the best of my knowledge.

This acknowledgement is required.

I agree that typing my name below serves as my electronic signature.

E-sign consent is required.

Electronic signature (type full name)

Please type your full name as signature.

Signature date

Please select a date.

Autosave: off

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