California RN Registry Participation Application — Pacific Private Nursing (Counsel-Review Draft)

First name

Last name

Preferred name (optional)

Phone

US phone number, e.g. (714) 555-1234 or +1 714 555 1234.

City

Postal code (optional)

California RN license number

Pacific independently verifies this number through the California Board of Registered Nursing / Department of Consumer Affairs.

License expiration date

Years licensed as an RN

Languages spoken (optional)

Clinical experience

Describe your clinical background in general terms. Do not include patient names or any identifying details about patients.

Specialties (optional — select any that apply)

Wound care

Post-surgical recovery

Geriatric care

Pediatric care

Infusion / IV therapy

Overnight care

Other specialty (optional)

General availability

Describe your general availability. This does not commit you to any specific assignment, schedule, or hours.

Current BLS/CPR certification?

Do not upload a certificate on this public form.

Professional liability coverage?

Do not provide a policy number or upload on this public form.

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

I understand that this application is not an employment offer or registry agreement and does not guarantee an assignment, schedule, hours, or income.

I authorize Pacific to verify publicly available California RN license and disciplinary-status information and to contact me about this application.

I acknowledge the Nurse Applicant Notice at Collection and Privacy Policy.

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