RN *Program Referral Form

 Department of Patient Care Services
 RN Program

 I would like to refer the following individual for employment with UAMS Medical Center.

Name _____________________________________________
Position Applied For _________________________________
Address ________________________________________
City _________________________ State ___________ 
Zip ______________
Work Phone ____________________ 
Home Phone _________________________

Referred by __________________________________________
Title/Position ________________________________________
Department ________________ 
# Regular Hours worked/Su.-Sa. ______
Supervisor ___________________________________ 
Work Phone ___________________________

Currently on written warning       yes  no
Employment Status/FTE    
Part-time (50% or greater)    Full-time
Inpatient Position listed as "Hard to Fill"         yes  no

Date ______________

This form must be completed and faxed to 501-686-5698 within 24 hours of submitted RN application. See the web site (www.uams.edu/don) for complete details, requirements, eligibility and qualifications.

To be completed by Nursing Business:
Eligible    yes  no

Date__________________ Initial___________________