fs25.formsite.com Open in urlscan Pro
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POST https://fs25.formsite.com/res/submit

<form method="post" id="FSForm" action="https://fs25.formsite.com/res/submit" enctype="multipart/form-data" onsubmit="return Vromansys.Form.processSubmit(this);">
  <div style="display:none">
    <input type="hidden" name="GenId" value="OnvHuYgZiAtadZC2">
    <input type="hidden" name="LocId" value="conneticsusa/kjplhzzf2y">
    <input type="hidden" name="EParam" value="AT1kKIiyxDzouCTG53lwGaeLTfEDMMCuFI4OUjw2ionFaXT9I_-PFkRpG5egZTmdPPm0B56tlNbNDAUjPAl5EJB6O66ChNul">
    <input type="hidden" name="ElapsedTime" id="ElapsedTime" value="0">
    <input type="hidden" name="Referrer" id="Referrer" value="">
    <input type="text" name="subject_line" id="subject_line" autocomplete="off"><label for="subject_line">subject_line</label>
  </div>
  <!-- BEGIN_ITEMS -->
  <div class="form_table">
    <div class="clear"></div>
    <div id="q19" class="q full_width">
      <a class="item_anchor" name="ItemAnchor0"></a>
      <div class="segment_header" style="background:#BAC332;width:auto;text-align:Left;">
        <h1 style="font-size:20px;padding-bottom:10px;padding-top:10px;">GENERAL INFORMATION</h1>
      </div>
    </div>
    <div class="clear"></div>
    <div id="q0" class="q required">
      <a class="item_anchor" name="ItemAnchor1"></a>
      <label class="question top_question" for="RESULT_TextField-1">First Name&nbsp;<b class="icon_required" style="color:#F00">*</b></label>
      <input type="text" name="RESULT_TextField-1" class="text_field" id="RESULT_TextField-1" size="27" value="">
    </div>
    <div id="q1" class="q required">
      <a class="item_anchor" name="ItemAnchor2"></a>
      <label class="question top_question" for="RESULT_TextField-2">Last Name&nbsp;<b class="icon_required" style="color:#F00">*</b></label>
      <input type="text" name="RESULT_TextField-2" class="text_field" id="RESULT_TextField-2" size="28" value="">
    </div>
    <div class="clear"></div>
    <div id="q5" class="q required">
      <a class="item_anchor" name="ItemAnchor3"></a>
      <label class="question top_question" for="RESULT_TextField-3">Email&nbsp;<b class="icon_required" style="color:#F00">*</b></label>
      <input type="email" name="RESULT_TextField-3" class="text_field" id="RESULT_TextField-3" size="64" value="">
    </div>
    <div class="clear"></div>
    <div id="q13" class="q required">
      <a class="item_anchor" name="ItemAnchor4"></a>
      <label class="question top_question" for="RESULT_TextField-4">Mobile Phone&nbsp;<b class="icon_required" style="color:#F00">*</b></label>
      <input type="text" name="RESULT_TextField-4" class="text_field" id="RESULT_TextField-4" size="33" value="">
    </div>
    <div id="q2" class="q required">
      <a class="item_anchor" name="ItemAnchor5"></a>
      <label class="question top_question" for="RESULT_TextField-5">Date of Birth&nbsp;<b class="icon_required" style="color:#F00">*</b></label>
      <input type="text" name="RESULT_TextField-5" class="text_field calendar_field hasDatepicker" id="RESULT_TextField-5" size="23" maxlength="10" date="yy-mm-dd" datemax="" datemin="" placeholder="yyyy-mm-dd" value="">&nbsp;<span
        class="icon_calendar"><span class="accessibility_hidden">+</span></span>
    </div>
    <div class="clear"></div>
    <div id="q18" class="q required">
      <a class="item_anchor" name="ItemAnchor6"></a>
      <label class="question top_question" for="RESULT_TextField-6">Citizenship&nbsp;<b class="icon_required" style="color:#F00">*</b></label>
      <input type="text" name="RESULT_TextField-6" class="text_field" id="RESULT_TextField-6" size="65" value="">
    </div>
    <div class="clear"></div>
    <div id="q17" class="q required">
      <a class="item_anchor" name="ItemAnchor7"></a>
      <label class="question top_question" for="RESULT_RadioButton-7">Country of Birth&nbsp;<b class="icon_required" style="color:#F00">*</b></label>
      <select id="RESULT_RadioButton-7" name="RESULT_RadioButton-7" class="drop_down">
        <option></option>
        <option value="Radio-0">Afghanistan</option>
        <option value="Radio-1">Albania</option>
        <option value="Radio-2">Algeria</option>
        <option value="Radio-3">Andorra</option>
        <option value="Radio-4">Angola</option>
        <option value="Radio-5">Antigua and Barbuda</option>
        <option value="Radio-6">Argentina</option>
        <option value="Radio-7">Armenia</option>
        <option value="Radio-8">Aruba</option>
        <option value="Radio-9">Australia</option>
        <option value="Radio-10">Austria</option>
        <option value="Radio-11">Azerbaijan</option>
        <option value="Radio-12">Bahamas, The</option>
        <option value="Radio-13">Bahrain</option>
        <option value="Radio-14">Bangladesh</option>
        <option value="Radio-15">Barbados</option>
        <option value="Radio-16">Belarus</option>
        <option value="Radio-17">Belgium</option>
        <option value="Radio-18">Belize</option>
        <option value="Radio-19">Benin</option>
        <option value="Radio-20">Bhutan</option>
        <option value="Radio-21">Bolivia</option>
        <option value="Radio-22">Bosnia and Herzegovina</option>
        <option value="Radio-23">Botswana</option>
        <option value="Radio-24">Brazil</option>
        <option value="Radio-25">Brunei</option>
        <option value="Radio-26">Bulgaria</option>
        <option value="Radio-27">Burkina Faso</option>
        <option value="Radio-28">Burma</option>
        <option value="Radio-29">Burundi</option>
        <option value="Radio-30">Cambodia</option>
        <option value="Radio-31">Cameroon</option>
        <option value="Radio-32">Canada</option>
        <option value="Radio-33">Cabo Verde</option>
        <option value="Radio-34">Central African Republic</option>
        <option value="Radio-35">Chad</option>
        <option value="Radio-36">Chile</option>
        <option value="Radio-37">China</option>
        <option value="Radio-38">Colombia</option>
        <option value="Radio-39">Comoros</option>
        <option value="Radio-40">Congo, Democratic Republic of the</option>
        <option value="Radio-41">Congo, Republic of the</option>
        <option value="Radio-42">Costa Rica</option>
        <option value="Radio-43">Cote d'Ivoire</option>
        <option value="Radio-44">Croatia</option>
        <option value="Radio-45">Cuba</option>
        <option value="Radio-46">Curacao</option>
        <option value="Radio-47">Cyprus</option>
        <option value="Radio-48">Czechia</option>
        <option value="Radio-49">Denmark</option>
        <option value="Radio-50">Djibouti</option>
        <option value="Radio-51">Dominica</option>
        <option value="Radio-52">Dominican Republic</option>
        <option value="Radio-53">East Timor</option>
        <option value="Radio-54">Ecuador</option>
        <option value="Radio-55">Egypt</option>
        <option value="Radio-56">El Salvador</option>
        <option value="Radio-57">Equatorial Guinea</option>
        <option value="Radio-58">Eritrea</option>
        <option value="Radio-59">Estonia</option>
        <option value="Radio-60">Ethiopia</option>
        <option value="Radio-61">Fiji</option>
        <option value="Radio-62">Finland</option>
        <option value="Radio-63">France</option>
        <option value="Radio-64">Gabon</option>
        <option value="Radio-65">Gambia, The</option>
        <option value="Radio-66">Georgia</option>
        <option value="Radio-67">Germany</option>
        <option value="Radio-68">Ghana</option>
        <option value="Radio-69">Greece</option>
        <option value="Radio-70">Grenada</option>
        <option value="Radio-71">Guatemala</option>
        <option value="Radio-72">Guinea</option>
        <option value="Radio-73">Guinea-Bissau</option>
        <option value="Radio-74">Guyana</option>
        <option value="Radio-75">Haiti</option>
        <option value="Radio-76">Holy See</option>
        <option value="Radio-77">Honduras</option>
        <option value="Radio-78">Hong Kong</option>
        <option value="Radio-79">Hungary</option>
        <option value="Radio-80">Iceland</option>
        <option value="Radio-81">India</option>
        <option value="Radio-82">Indonesia</option>
        <option value="Radio-83">Iran</option>
        <option value="Radio-84">Iraq</option>
        <option value="Radio-85">Ireland</option>
        <option value="Radio-86">Israel</option>
        <option value="Radio-87">Italy</option>
        <option value="Radio-88">Jamaica</option>
        <option value="Radio-89">Japan</option>
        <option value="Radio-90">Jordan</option>
        <option value="Radio-91">Kazakhstan</option>
        <option value="Radio-92">Kenya</option>
        <option value="Radio-93">Kiribati</option>
        <option value="Radio-94">Korea, North</option>
        <option value="Radio-95">Korea, South</option>
        <option value="Radio-96">Kosovo</option>
        <option value="Radio-97">Kuwait</option>
        <option value="Radio-98">Kyrgyzstan</option>
        <option value="Radio-99">Laos</option>
        <option value="Radio-100">Latvia</option>
        <option value="Radio-101">Lebanon</option>
        <option value="Radio-102">Lesotho</option>
        <option value="Radio-103">Liberia</option>
        <option value="Radio-104">Libya</option>
        <option value="Radio-105">Liechtenstein</option>
        <option value="Radio-106">Lithuania</option>
        <option value="Radio-107">Luxembourg</option>
        <option value="Radio-108">Macau</option>
        <option value="Radio-109">Macedonia</option>
        <option value="Radio-110">Madagascar</option>
        <option value="Radio-111">Malawi</option>
        <option value="Radio-112">Malaysia</option>
        <option value="Radio-113">Maldives</option>
        <option value="Radio-114">Mali</option>
        <option value="Radio-115">Malta</option>
        <option value="Radio-116">Marshall Islands</option>
        <option value="Radio-117">Mauritania</option>
        <option value="Radio-118">Mauritius</option>
        <option value="Radio-119">Mexico</option>
        <option value="Radio-120">Micronesia</option>
        <option value="Radio-121">Moldova</option>
        <option value="Radio-122">Monaco</option>
        <option value="Radio-123">Mongolia</option>
        <option value="Radio-124">Montenegro</option>
        <option value="Radio-125">Morocco</option>
        <option value="Radio-126">Mozambique</option>
        <option value="Radio-127">Namibia</option>
        <option value="Radio-128">Nauru</option>
        <option value="Radio-129">Nepal</option>
        <option value="Radio-130">Netherlands</option>
        <option value="Radio-131">New Zealand</option>
        <option value="Radio-132">Nicaragua</option>
        <option value="Radio-133">Niger</option>
        <option value="Radio-134">Nigeria</option>
        <option value="Radio-135">North Korea</option>
        <option value="Radio-136">Norway</option>
        <option value="Radio-137">Oman</option>
        <option value="Radio-138">Pakistan</option>
        <option value="Radio-139">Palau</option>
        <option value="Radio-140">Palestinian Territories</option>
        <option value="Radio-141">Panama</option>
        <option value="Radio-142">Papua New Guinea</option>
        <option value="Radio-143">Paraguay</option>
        <option value="Radio-144">Peru</option>
        <option value="Radio-145">Philippines</option>
        <option value="Radio-146">Poland</option>
        <option value="Radio-147">Portugal</option>
        <option value="Radio-148">Qatar</option>
        <option value="Radio-149">Romania</option>
        <option value="Radio-150">Russia</option>
        <option value="Radio-151">Rwanda</option>
        <option value="Radio-152">Saint Kitts and Nevis</option>
        <option value="Radio-153">Saint Lucia</option>
        <option value="Radio-154">Saint Vincent and the Grenadines</option>
        <option value="Radio-155">Samoa</option>
        <option value="Radio-156">San Marino</option>
        <option value="Radio-157">Sao Tome and Principe</option>
        <option value="Radio-158">Saudi Arabia</option>
        <option value="Radio-159">Senegal</option>
        <option value="Radio-160">Serbia</option>
        <option value="Radio-161">Seychelles</option>
        <option value="Radio-162">Sierra Leone</option>
        <option value="Radio-163">Singapore</option>
        <option value="Radio-164">Sint Maarten</option>
        <option value="Radio-165">Slovakia</option>
        <option value="Radio-166">Slovenia</option>
        <option value="Radio-167">Solomon Islands</option>
        <option value="Radio-168">Somalia</option>
        <option value="Radio-169">South Africa</option>
        <option value="Radio-170">South Korea</option>
        <option value="Radio-171">South Sudan</option>
        <option value="Radio-172">Spain</option>
        <option value="Radio-173">Sri Lanka</option>
        <option value="Radio-174">Sudan</option>
        <option value="Radio-175">Suriname</option>
        <option value="Radio-176">Swaziland</option>
        <option value="Radio-177">Sweden</option>
        <option value="Radio-178">Switzerland</option>
        <option value="Radio-179">Syria</option>
        <option value="Radio-180">Taiwan</option>
        <option value="Radio-181">Tajikistan</option>
        <option value="Radio-182">Tanzania</option>
        <option value="Radio-183">Thailand</option>
        <option value="Radio-184">Timor-Leste</option>
        <option value="Radio-185">Togo</option>
        <option value="Radio-186">Tonga</option>
        <option value="Radio-187">Trinidad and Tobago</option>
        <option value="Radio-188">Tunisia</option>
        <option value="Radio-189">Turkey</option>
        <option value="Radio-190">Turkmenistan</option>
        <option value="Radio-191">Tuvalu</option>
        <option value="Radio-192">Uganda</option>
        <option value="Radio-193">Ukraine</option>
        <option value="Radio-194">United Arab Emirates</option>
        <option value="Radio-195">United Kingdom</option>
        <option value="Radio-196">United States</option>
        <option value="Radio-197">Uruguay</option>
        <option value="Radio-198">Uzbekistan</option>
        <option value="Radio-199">Vanuatu</option>
        <option value="Radio-200">Venezuela</option>
        <option value="Radio-201">Vietnam</option>
        <option value="Radio-202">Yemen</option>
        <option value="Radio-203">Zambia</option>
        <option value="Radio-204">Zimbabwe</option>
      </select>
    </div>
    <div id="q16" class="q required">
      <a class="item_anchor" name="ItemAnchor8"></a>
      <label class="question top_question" for="RESULT_RadioButton-8">Current Country of Residence&nbsp;<b class="icon_required" style="color:#F00">*</b></label>
      <select id="RESULT_RadioButton-8" name="RESULT_RadioButton-8" class="drop_down">
        <option></option>
        <option value="Radio-0">Afghanistan</option>
        <option value="Radio-1">Albania</option>
        <option value="Radio-2">Algeria</option>
        <option value="Radio-3">Andorra</option>
        <option value="Radio-4">Angola</option>
        <option value="Radio-5">Antigua and Barbuda</option>
        <option value="Radio-6">Argentina</option>
        <option value="Radio-7">Armenia</option>
        <option value="Radio-8">Aruba</option>
        <option value="Radio-9">Australia</option>
        <option value="Radio-10">Austria</option>
        <option value="Radio-11">Azerbaijan</option>
        <option value="Radio-12">Bahamas, The</option>
        <option value="Radio-13">Bahrain</option>
        <option value="Radio-14">Bangladesh</option>
        <option value="Radio-15">Barbados</option>
        <option value="Radio-16">Belarus</option>
        <option value="Radio-17">Belgium</option>
        <option value="Radio-18">Belize</option>
        <option value="Radio-19">Benin</option>
        <option value="Radio-20">Bhutan</option>
        <option value="Radio-21">Bolivia</option>
        <option value="Radio-22">Bosnia and Herzegovina</option>
        <option value="Radio-23">Botswana</option>
        <option value="Radio-24">Brazil</option>
        <option value="Radio-25">Brunei</option>
        <option value="Radio-26">Bulgaria</option>
        <option value="Radio-27">Burkina Faso</option>
        <option value="Radio-28">Burma</option>
        <option value="Radio-29">Burundi</option>
        <option value="Radio-30">Cambodia</option>
        <option value="Radio-31">Cameroon</option>
        <option value="Radio-32">Canada</option>
        <option value="Radio-33">Cabo Verde</option>
        <option value="Radio-34">Central African Republic</option>
        <option value="Radio-35">Chad</option>
        <option value="Radio-36">Chile</option>
        <option value="Radio-37">China</option>
        <option value="Radio-38">Colombia</option>
        <option value="Radio-39">Comoros</option>
        <option value="Radio-40">Congo, Democratic Republic of the</option>
        <option value="Radio-41">Congo, Republic of the</option>
        <option value="Radio-42">Costa Rica</option>
        <option value="Radio-43">Cote d'Ivoire</option>
        <option value="Radio-44">Croatia</option>
        <option value="Radio-45">Cuba</option>
        <option value="Radio-46">Curacao</option>
        <option value="Radio-47">Cyprus</option>
        <option value="Radio-48">Czechia</option>
        <option value="Radio-49">Denmark</option>
        <option value="Radio-50">Djibouti</option>
        <option value="Radio-51">Dominica</option>
        <option value="Radio-52">Dominican Republic</option>
        <option value="Radio-53">East Timor</option>
        <option value="Radio-54">Ecuador</option>
        <option value="Radio-55">Egypt</option>
        <option value="Radio-56">El Salvador</option>
        <option value="Radio-57">Equatorial Guinea</option>
        <option value="Radio-58">Eritrea</option>
        <option value="Radio-59">Estonia</option>
        <option value="Radio-60">Ethiopia</option>
        <option value="Radio-61">Fiji</option>
        <option value="Radio-62">Finland</option>
        <option value="Radio-63">France</option>
        <option value="Radio-64">Gabon</option>
        <option value="Radio-65">Gambia, The</option>
        <option value="Radio-66">Georgia</option>
        <option value="Radio-67">Germany</option>
        <option value="Radio-68">Ghana</option>
        <option value="Radio-69">Greece</option>
        <option value="Radio-70">Grenada</option>
        <option value="Radio-71">Guatemala</option>
        <option value="Radio-72">Guinea</option>
        <option value="Radio-73">Guinea-Bissau</option>
        <option value="Radio-74">Guyana</option>
        <option value="Radio-75">Haiti</option>
        <option value="Radio-76">Holy See</option>
        <option value="Radio-77">Honduras</option>
        <option value="Radio-78">Hong Kong</option>
        <option value="Radio-79">Hungary</option>
        <option value="Radio-80">Iceland</option>
        <option value="Radio-81">India</option>
        <option value="Radio-82">Indonesia</option>
        <option value="Radio-83">Iran</option>
        <option value="Radio-84">Iraq</option>
        <option value="Radio-85">Ireland</option>
        <option value="Radio-86">Israel</option>
        <option value="Radio-87">Italy</option>
        <option value="Radio-88">Jamaica</option>
        <option value="Radio-89">Japan</option>
        <option value="Radio-90">Jordan</option>
        <option value="Radio-91">Kazakhstan</option>
        <option value="Radio-92">Kenya</option>
        <option value="Radio-93">Kiribati</option>
        <option value="Radio-94">Korea, North</option>
        <option value="Radio-95">Korea, South</option>
        <option value="Radio-96">Kosovo</option>
        <option value="Radio-97">Kuwait</option>
        <option value="Radio-98">Kyrgyzstan</option>
        <option value="Radio-99">Laos</option>
        <option value="Radio-100">Latvia</option>
        <option value="Radio-101">Lebanon</option>
        <option value="Radio-102">Lesotho</option>
        <option value="Radio-103">Liberia</option>
        <option value="Radio-104">Libya</option>
        <option value="Radio-105">Liechtenstein</option>
        <option value="Radio-106">Lithuania</option>
        <option value="Radio-107">Luxembourg</option>
        <option value="Radio-108">Macau</option>
        <option value="Radio-109">Macedonia</option>
        <option value="Radio-110">Madagascar</option>
        <option value="Radio-111">Malawi</option>
        <option value="Radio-112">Malaysia</option>
        <option value="Radio-113">Maldives</option>
        <option value="Radio-114">Mali</option>
        <option value="Radio-115">Malta</option>
        <option value="Radio-116">Marshall Islands</option>
        <option value="Radio-117">Mauritania</option>
        <option value="Radio-118">Mauritius</option>
        <option value="Radio-119">Mexico</option>
        <option value="Radio-120">Micronesia</option>
        <option value="Radio-121">Moldova</option>
        <option value="Radio-122">Monaco</option>
        <option value="Radio-123">Mongolia</option>
        <option value="Radio-124">Montenegro</option>
        <option value="Radio-125">Morocco</option>
        <option value="Radio-126">Mozambique</option>
        <option value="Radio-127">Namibia</option>
        <option value="Radio-128">Nauru</option>
        <option value="Radio-129">Nepal</option>
        <option value="Radio-130">Netherlands</option>
        <option value="Radio-131">New Zealand</option>
        <option value="Radio-132">Nicaragua</option>
        <option value="Radio-133">Niger</option>
        <option value="Radio-134">Nigeria</option>
        <option value="Radio-135">North Korea</option>
        <option value="Radio-136">Norway</option>
        <option value="Radio-137">Oman</option>
        <option value="Radio-138">Pakistan</option>
        <option value="Radio-139">Palau</option>
        <option value="Radio-140">Palestinian Territories</option>
        <option value="Radio-141">Panama</option>
        <option value="Radio-142">Papua New Guinea</option>
        <option value="Radio-143">Paraguay</option>
        <option value="Radio-144">Peru</option>
        <option value="Radio-145">Philippines</option>
        <option value="Radio-146">Poland</option>
        <option value="Radio-147">Portugal</option>
        <option value="Radio-148">Qatar</option>
        <option value="Radio-149">Romania</option>
        <option value="Radio-150">Russia</option>
        <option value="Radio-151">Rwanda</option>
        <option value="Radio-152">Saint Kitts and Nevis</option>
        <option value="Radio-153">Saint Lucia</option>
        <option value="Radio-154">Saint Vincent and the Grenadines</option>
        <option value="Radio-155">Samoa</option>
        <option value="Radio-156">San Marino</option>
        <option value="Radio-157">Sao Tome and Principe</option>
        <option value="Radio-158">Saudi Arabia</option>
        <option value="Radio-159">Senegal</option>
        <option value="Radio-160">Serbia</option>
        <option value="Radio-161">Seychelles</option>
        <option value="Radio-162">Sierra Leone</option>
        <option value="Radio-163">Singapore</option>
        <option value="Radio-164">Sint Maarten</option>
        <option value="Radio-165">Slovakia</option>
        <option value="Radio-166">Slovenia</option>
        <option value="Radio-167">Solomon Islands</option>
        <option value="Radio-168">Somalia</option>
        <option value="Radio-169">South Africa</option>
        <option value="Radio-170">South Korea</option>
        <option value="Radio-171">South Sudan</option>
        <option value="Radio-172">Spain</option>
        <option value="Radio-173">Sri Lanka</option>
        <option value="Radio-174">Sudan</option>
        <option value="Radio-175">Suriname</option>
        <option value="Radio-176">Swaziland</option>
        <option value="Radio-177">Sweden</option>
        <option value="Radio-178">Switzerland</option>
        <option value="Radio-179">Syria</option>
        <option value="Radio-180">Taiwan</option>
        <option value="Radio-181">Tajikistan</option>
        <option value="Radio-182">Tanzania</option>
        <option value="Radio-183">Thailand</option>
        <option value="Radio-184">Timor-Leste</option>
        <option value="Radio-185">Togo</option>
        <option value="Radio-186">Tonga</option>
        <option value="Radio-187">Trinidad and Tobago</option>
        <option value="Radio-188">Tunisia</option>
        <option value="Radio-189">Turkey</option>
        <option value="Radio-190">Turkmenistan</option>
        <option value="Radio-191">Tuvalu</option>
        <option value="Radio-192">Uganda</option>
        <option value="Radio-193">Ukraine</option>
        <option value="Radio-194">United Arab Emirates</option>
        <option value="Radio-195">United Kingdom</option>
        <option value="Radio-196">United States</option>
        <option value="Radio-197">Uruguay</option>
        <option value="Radio-198">Uzbekistan</option>
        <option value="Radio-199">Vanuatu</option>
        <option value="Radio-200">Venezuela</option>
        <option value="Radio-201">Vietnam</option>
        <option value="Radio-202">Yemen</option>
        <option value="Radio-203">Zambia</option>
        <option value="Radio-204">Zimbabwe</option>
      </select>
    </div>
    <div class="clear"></div>
    <div id="q42" style="display:none" class="q">
      <a class="item_anchor" name="ItemAnchor9"></a>
      <input type="hidden" name="RESULT_TextField-9" class="text_field" id="RESULT_TextField-9" size="25" value="northside">
    </div>
    <div class="clear"></div>
    <div id="q46" style="display:none" class="q">
      <a class="item_anchor" name="ItemAnchor10"></a>
      <input type="hidden" name="RESULT_TextField-10" class="text_field" id="RESULT_TextField-10" size="25" value="">
    </div>
    <div class="clear"></div>
    <div id="q20" class="q full_width">
      <a class="item_anchor" name="ItemAnchor11"></a>
      <div class="segment_header" style="background:#BAC332;width:auto;text-align:Left;">
        <h1 style="font-size:20px;padding-bottom:10px;padding-top:10px;">EDUCATION &amp; WORK EXPERIENCE</h1>
      </div>
    </div>
    <div class="clear"></div>
    <div id="q21" class="q required">
      <a class="item_anchor" name="ItemAnchor12"></a>
      <span class="question top_question">Are you currently working (or have you been working within the past year) as a registered nurse in a hospital setting?&nbsp;<b class="icon_required" style="color:#F00">*</b></span>
      <table class="inline_grid choices">
        <tbody>
          <tr>
            <td><input type="radio" name="RESULT_RadioButton-12" class="multiple_choice" id="RESULT_RadioButton-12_0" value="Radio-0"><label for="RESULT_RadioButton-12_0">Yes</label></td>
          </tr>
          <tr>
            <td><input type="radio" name="RESULT_RadioButton-12" class="multiple_choice" id="RESULT_RadioButton-12_1" value="Radio-1"><label for="RESULT_RadioButton-12_1">No</label></td>
          </tr>
        </tbody>
      </table>
    </div>
    <div class="clear"></div>
    <div id="q37" class="q required">
      <a class="item_anchor" name="ItemAnchor13"></a>
      <span class="question top_question">Do you have 1 year RN experience in a Hospital or Home Health setting?&nbsp;<b class="icon_required" style="color:#F00">*</b></span>
      <table class="inline_grid choices">
        <tbody>
          <tr>
            <td><input type="radio" name="RESULT_RadioButton-13" class="multiple_choice" id="RESULT_RadioButton-13_0" value="Radio-0"><label for="RESULT_RadioButton-13_0">Yes</label></td>
          </tr>
          <tr>
            <td><input type="radio" name="RESULT_RadioButton-13" class="multiple_choice" id="RESULT_RadioButton-13_1" value="Radio-1"><label for="RESULT_RadioButton-13_1">No</label></td>
          </tr>
        </tbody>
      </table>
    </div>
    <div class="clear"></div>
    <div id="q22" class="q required">
      <a class="item_anchor" name="ItemAnchor14"></a>
      <label class="question top_question" for="RESULT_RadioButton-14">What is your current specialty?&nbsp;<b class="icon_required" style="color:#F00">*</b></label>
      <select id="RESULT_RadioButton-14" name="RESULT_RadioButton-14" class="drop_down">
        <option></option>
        <option value="Radio-0">Not Applicable</option>
        <option value="Radio-1">Acute Medical Unit</option>
        <option value="Radio-2">ACUTE SURGICAL ONCOLOGY</option>
        <option value="Radio-3">Ambulatory</option>
        <option value="Radio-4">Blood Bank</option>
        <option value="Radio-5">Burns and Plastics</option>
        <option value="Radio-6">Cardiology</option>
        <option value="Radio-7">Casualty</option>
        <option value="Radio-8">Cath Lab</option>
        <option value="Radio-9">Certified Nursing Aide (CNA)</option>
        <option value="Radio-10">Coronary Care Unit (CCU)</option>
        <option value="Radio-11">CVICU</option>
        <option value="Radio-12">Day Surgery</option>
        <option value="Radio-13">Dialysis</option>
        <option value="Radio-14">Endoscopy</option>
        <option value="Radio-15">ER</option>
        <option value="Radio-16">ER - Pedia</option>
        <option value="Radio-17">Geriatric</option>
        <option value="Radio-18">HDU</option>
        <option value="Radio-19">Healthcare Aide (HCA)</option>
        <option value="Radio-20">Hematology</option>
        <option value="Radio-21">Hemodialysis</option>
        <option value="Radio-22">Home Care</option>
        <option value="Radio-23">Home Health</option>
        <option value="Radio-24">ICU</option>
        <option value="Radio-25">ICU - Cardiac ICU</option>
        <option value="Radio-26">ICU - CVICU</option>
        <option value="Radio-27">ICU - MICU</option>
        <option value="Radio-28">ICU - Neuro ICU</option>
        <option value="Radio-29">ICU - NICU</option>
        <option value="Radio-30">ICU - PICU</option>
        <option value="Radio-31">ICU - SICU</option>
        <option value="Radio-32">L &amp; D</option>
        <option value="Radio-33">Long-term Care (LTC)</option>
        <option value="Radio-34">Med / Surg</option>
        <option value="Radio-35">Medical</option>
        <option value="Radio-36">Medical &amp; Surgical ICU</option>
        <option value="Radio-37">Medical Technologist (MT / MedTech)</option>
        <option value="Radio-38">Need Experience</option>
        <option value="Radio-39">Neuro- Rehab</option>
        <option value="Radio-40">Neurology</option>
        <option value="Radio-41">New Grad</option>
        <option value="Radio-42">Not Applicable</option>
        <option value="Radio-43">Nursery</option>
        <option value="Radio-44">OB - Gyne</option>
        <option value="Radio-45">Occupational Therapist (OT)</option>
        <option value="Radio-46">Onco / Hema</option>
        <option value="Radio-47">Oncology</option>
        <option value="Radio-48">OPD</option>
        <option value="Radio-49">OR</option>
        <option value="Radio-50">OR - CVOR</option>
        <option value="Radio-51">OR - Ophthalmology</option>
        <option value="Radio-52">OR-PACU</option>
        <option value="Radio-53">OR/ Day Surgery</option>
        <option value="Radio-54">Orthopedic</option>
        <option value="Radio-55">Other</option>
        <option value="Radio-56">PACU</option>
        <option value="Radio-57">Paediatric Cardiac Medical &amp; Surgical ICU</option>
        <option value="Radio-58">Palliative Care</option>
        <option value="Radio-59">PCU</option>
        <option value="Radio-60">Pedia</option>
        <option value="Radio-61">Pediatric OR</option>
        <option value="Radio-62">Personal Support Worker (PSW)</option>
        <option value="Radio-63">Physical Therapist (PT)</option>
        <option value="Radio-64">Post - Partum</option>
        <option value="Radio-65">Private Duty Nurse</option>
        <option value="Radio-66">Psych / Mental Health</option>
        <option value="Radio-67">Radiology</option>
        <option value="Radio-68">Rehab</option>
        <option value="Radio-69">SBCU</option>
        <option value="Radio-70">School Nurse</option>
        <option value="Radio-71">Step Down Unit</option>
        <option value="Radio-72">Surgical</option>
        <option value="Radio-73">Telemetry</option>
        <option value="Radio-74">Trauma ICU</option>
        <option value="Radio-75">Urgent Care</option>
      </select>
    </div>
    <div class="clear"></div>
    <div id="q23" class="q required">
      <a class="item_anchor" name="ItemAnchor15"></a>
      <label class="question top_question" for="RESULT_RadioButton-15">What is your current profession?&nbsp;<b class="icon_required" style="color:#F00">*</b></label>
      <select id="RESULT_RadioButton-15" name="RESULT_RadioButton-15" class="drop_down">
        <option></option>
        <option value="Radio-0">Not working</option>
        <option value="Radio-1">Registered Nurse (RN)</option>
        <option value="Radio-2">Licensed Practical Nurse (LPN)</option>
        <option value="Radio-3">Registered Practical Nurse (RPN)</option>
        <option value="Radio-4">Certified Nursing Assistant (CNA)</option>
        <option value="Radio-5">Healthcare Aide (HCA)</option>
        <option value="Radio-6">Medical Doctor (MD)</option>
        <option value="Radio-7">Medical Technologist (MT / MedTech)</option>
        <option value="Radio-8">Occupational Therapist (OT)</option>
        <option value="Radio-9">Physical Therapist (PT)</option>
        <option value="Radio-10">Other</option>
      </select>
    </div>
    <div class="clear"></div>
    <div id="q24" class="q required">
      <a class="item_anchor" name="ItemAnchor16"></a>
      <span class="question top_question">Have you passed the NCLEX?&nbsp;<b class="icon_required" style="color:#F00">*</b></span>
      <table class="inline_grid choices">
        <tbody>
          <tr>
            <td><input type="radio" name="RESULT_RadioButton-16" class="multiple_choice" id="RESULT_RadioButton-16_0" value="Radio-0"><label for="RESULT_RadioButton-16_0">Yes</label></td>
          </tr>
          <tr>
            <td><input type="radio" name="RESULT_RadioButton-16" class="multiple_choice" id="RESULT_RadioButton-16_1" value="Radio-1"><label for="RESULT_RadioButton-16_1">No</label></td>
          </tr>
        </tbody>
      </table>
    </div>
    <div class="clear"></div>
    <div id="q36" class="q required">
      <a class="item_anchor" name="ItemAnchor17"></a>
      <span class="question top_question">Do you have a Bachelor's Degree or Master's Degree in Nursing?&nbsp;<b class="icon_required" style="color:#F00">*</b></span>
      <table class="inline_grid choices">
        <tbody>
          <tr>
            <td><input type="radio" name="RESULT_RadioButton-17" class="multiple_choice" id="RESULT_RadioButton-17_0" value="Radio-0"><label for="RESULT_RadioButton-17_0">Yes</label></td>
          </tr>
          <tr>
            <td><input type="radio" name="RESULT_RadioButton-17" class="multiple_choice" id="RESULT_RadioButton-17_1" value="Radio-1"><label for="RESULT_RadioButton-17_1">No</label></td>
          </tr>
        </tbody>
      </table>
    </div>
    <div class="clear"></div>
    <div id="q25" class="q required">
      <a class="item_anchor" name="ItemAnchor18"></a>
      <label class="question top_question" for="RESULT_RadioButton-18">Have you passed the English exam (IELTS/TOEFL)?&nbsp;<b class="icon_required" style="color:#F00">*</b></label>
      <select id="RESULT_RadioButton-18" name="RESULT_RadioButton-18" class="drop_down">
        <option></option>
        <option value="Radio-0">Pass</option>
        <option value="Radio-1">Fail</option>
        <option value="Radio-2">Expired</option>
        <option value="Radio-3">No</option>
        <option value="Radio-4">Scheduled</option>
        <option value="Radio-5">Waiting for results</option>
        <option value="Radio-6">N/A</option>
        <option value="Radio-7">TOEFL IBT</option>
        <option value="Radio-8">Rescore</option>
        <option value="Radio-9">Pending Re-take</option>
      </select>
    </div>
    <div class="clear"></div>
    <div id="q26" class="q required">
      <a class="item_anchor" name="ItemAnchor19"></a>
      <span class="question top_question">Do you have a previously-filed employment-based Green Card (I-140) petition?&nbsp;<b class="icon_required" style="color:#F00">*</b></span>
      <table class="inline_grid choices">
        <tbody>
          <tr>
            <td><input type="radio" name="RESULT_RadioButton-19" class="multiple_choice" id="RESULT_RadioButton-19_0" value="Radio-0"><label for="RESULT_RadioButton-19_0">Yes</label></td>
          </tr>
          <tr>
            <td><input type="radio" name="RESULT_RadioButton-19" class="multiple_choice" id="RESULT_RadioButton-19_1" value="Radio-1"><label for="RESULT_RadioButton-19_1">No</label></td>
          </tr>
        </tbody>
      </table>
    </div>
    <div class="clear"></div>
    <div id="q35" class="q required">
      <a class="item_anchor" name="ItemAnchor20"></a>
      <span class="question top_question">Has your previously filed Green Card (I-140) petition been approved?&nbsp;<b class="icon_required" style="color:#F00">*</b></span>
      <table class="inline_grid choices">
        <tbody>
          <tr>
            <td><input type="radio" name="RESULT_RadioButton-20" class="multiple_choice" id="RESULT_RadioButton-20_0" value="Radio-0"><label for="RESULT_RadioButton-20_0">Yes</label></td>
          </tr>
          <tr>
            <td><input type="radio" name="RESULT_RadioButton-20" class="multiple_choice" id="RESULT_RadioButton-20_1" value="Radio-1"><label for="RESULT_RadioButton-20_1">No</label></td>
          </tr>
        </tbody>
      </table>
    </div>
    <div class="clear"></div>
    <div id="q48" class="q">
      <a class="item_anchor" name="ItemAnchor21"></a>
      <label class="question top_question" for="RESULT_RadioButton-21">What is your preferred US State of employment? (1st choice)</label>
      <select id="RESULT_RadioButton-21" name="RESULT_RadioButton-21" class="drop_down">
        <option></option>
        <option value="Radio-0">Any</option>
        <option value="Radio-1">Alabama</option>
        <option value="Radio-2">Alaska</option>
        <option value="Radio-3">Arizona</option>
        <option value="Radio-4">Arkansas</option>
        <option value="Radio-5">California</option>
        <option value="Radio-6">Colorado</option>
        <option value="Radio-7">Connecticut</option>
        <option value="Radio-8">Delaware</option>
        <option value="Radio-9">Florida</option>
        <option value="Radio-10">Georgia</option>
        <option value="Radio-11">Hawaii</option>
        <option value="Radio-12">Idaho</option>
        <option value="Radio-13">Illinois</option>
        <option value="Radio-14">Indiana</option>
        <option value="Radio-15">Iowa</option>
        <option value="Radio-16">Kansas</option>
        <option value="Radio-17">Kentucky</option>
        <option value="Radio-18">Louisiana</option>
        <option value="Radio-19">Maine</option>
        <option value="Radio-20">Maryland</option>
        <option value="Radio-21">Massachusetts</option>
        <option value="Radio-22">Michigan</option>
        <option value="Radio-23">Minnesota</option>
        <option value="Radio-24">Mississippi</option>
        <option value="Radio-25">Missouri</option>
        <option value="Radio-26">Montana</option>
        <option value="Radio-27">Nebraska</option>
        <option value="Radio-28">Nevada</option>
        <option value="Radio-29">New Hampshire</option>
        <option value="Radio-30">New Jersey</option>
        <option value="Radio-31">New Mexico</option>
        <option value="Radio-32">New York</option>
        <option value="Radio-33">North Carolina</option>
        <option value="Radio-34">North Dakota</option>
        <option value="Radio-35">Ohio</option>
        <option value="Radio-36">Oklahoma</option>
        <option value="Radio-37">Oregon</option>
        <option value="Radio-38">Pennsylvania</option>
        <option value="Radio-39">Rhode Island</option>
        <option value="Radio-40">South Carolina</option>
        <option value="Radio-41">South Dakota</option>
        <option value="Radio-42">Tennessee</option>
        <option value="Radio-43">Texas</option>
        <option value="Radio-44">Utah</option>
        <option value="Radio-45">Vermont</option>
        <option value="Radio-46">Virginia</option>
        <option value="Radio-47">Washington</option>
        <option value="Radio-48">West Virginia</option>
        <option value="Radio-49">Wisconsin</option>
        <option value="Radio-50">Wyoming</option>
        <option value="Radio-51">Washington DC</option>
      </select>
    </div>
    <div class="clear"></div>
    <div id="q49" class="q">
      <a class="item_anchor" name="ItemAnchor22"></a>
      <label class="question top_question" for="RESULT_RadioButton-22">What is your preferred US State of employment? (2nd choice)</label>
      <select id="RESULT_RadioButton-22" name="RESULT_RadioButton-22" class="drop_down">
        <option></option>
        <option value="Radio-0">Any</option>
        <option value="Radio-1">Alabama</option>
        <option value="Radio-2">Alaska</option>
        <option value="Radio-3">Arizona</option>
        <option value="Radio-4">Arkansas</option>
        <option value="Radio-5">California</option>
        <option value="Radio-6">Colorado</option>
        <option value="Radio-7">Connecticut</option>
        <option value="Radio-8">Delaware</option>
        <option value="Radio-9">Florida</option>
        <option value="Radio-10">Georgia</option>
        <option value="Radio-11">Hawaii</option>
        <option value="Radio-12">Idaho</option>
        <option value="Radio-13">Illinois</option>
        <option value="Radio-14">Indiana</option>
        <option value="Radio-15">Iowa</option>
        <option value="Radio-16">Kansas</option>
        <option value="Radio-17">Kentucky</option>
        <option value="Radio-18">Louisiana</option>
        <option value="Radio-19">Maine</option>
        <option value="Radio-20">Maryland</option>
        <option value="Radio-21">Massachusetts</option>
        <option value="Radio-22">Michigan</option>
        <option value="Radio-23">Minnesota</option>
        <option value="Radio-24">Mississippi</option>
        <option value="Radio-25">Missouri</option>
        <option value="Radio-26">Montana</option>
        <option value="Radio-27">Nebraska</option>
        <option value="Radio-28">Nevada</option>
        <option value="Radio-29">New Hampshire</option>
        <option value="Radio-30">New Jersey</option>
        <option value="Radio-31">New Mexico</option>
        <option value="Radio-32">New York</option>
        <option value="Radio-33">North Carolina</option>
        <option value="Radio-34">North Dakota</option>
        <option value="Radio-35">Ohio</option>
        <option value="Radio-36">Oklahoma</option>
        <option value="Radio-37">Oregon</option>
        <option value="Radio-38">Pennsylvania</option>
        <option value="Radio-39">Rhode Island</option>
        <option value="Radio-40">South Carolina</option>
        <option value="Radio-41">South Dakota</option>
        <option value="Radio-42">Tennessee</option>
        <option value="Radio-43">Texas</option>
        <option value="Radio-44">Utah</option>
        <option value="Radio-45">Vermont</option>
        <option value="Radio-46">Virginia</option>
        <option value="Radio-47">Washington</option>
        <option value="Radio-48">West Virginia</option>
        <option value="Radio-49">Wisconsin</option>
        <option value="Radio-50">Wyoming</option>
        <option value="Radio-51">Washington DC</option>
      </select>
    </div>
    <div class="clear"></div>
    <div id="q50" class="q">
      <a class="item_anchor" name="ItemAnchor23"></a>
      <label class="question top_question" for="RESULT_RadioButton-23">What is your preferred US State of employment? (3rd choice)</label>
      <select id="RESULT_RadioButton-23" name="RESULT_RadioButton-23" class="drop_down">
        <option></option>
        <option value="Radio-0">Any</option>
        <option value="Radio-1">Alabama</option>
        <option value="Radio-2">Alaska</option>
        <option value="Radio-3">Arizona</option>
        <option value="Radio-4">Arkansas</option>
        <option value="Radio-5">California</option>
        <option value="Radio-6">Colorado</option>
        <option value="Radio-7">Connecticut</option>
        <option value="Radio-8">Delaware</option>
        <option value="Radio-9">Florida</option>
        <option value="Radio-10">Georgia</option>
        <option value="Radio-11">Hawaii</option>
        <option value="Radio-12">Idaho</option>
        <option value="Radio-13">Illinois</option>
        <option value="Radio-14">Indiana</option>
        <option value="Radio-15">Iowa</option>
        <option value="Radio-16">Kansas</option>
        <option value="Radio-17">Kentucky</option>
        <option value="Radio-18">Louisiana</option>
        <option value="Radio-19">Maine</option>
        <option value="Radio-20">Maryland</option>
        <option value="Radio-21">Massachusetts</option>
        <option value="Radio-22">Michigan</option>
        <option value="Radio-23">Minnesota</option>
        <option value="Radio-24">Mississippi</option>
        <option value="Radio-25">Missouri</option>
        <option value="Radio-26">Montana</option>
        <option value="Radio-27">Nebraska</option>
        <option value="Radio-28">Nevada</option>
        <option value="Radio-29">New Hampshire</option>
        <option value="Radio-30">New Jersey</option>
        <option value="Radio-31">New Mexico</option>
        <option value="Radio-32">New York</option>
        <option value="Radio-33">North Carolina</option>
        <option value="Radio-34">North Dakota</option>
        <option value="Radio-35">Ohio</option>
        <option value="Radio-36">Oklahoma</option>
        <option value="Radio-37">Oregon</option>
        <option value="Radio-38">Pennsylvania</option>
        <option value="Radio-39">Rhode Island</option>
        <option value="Radio-40">South Carolina</option>
        <option value="Radio-41">South Dakota</option>
        <option value="Radio-42">Tennessee</option>
        <option value="Radio-43">Texas</option>
        <option value="Radio-44">Utah</option>
        <option value="Radio-45">Vermont</option>
        <option value="Radio-46">Virginia</option>
        <option value="Radio-47">Washington</option>
        <option value="Radio-48">West Virginia</option>
        <option value="Radio-49">Wisconsin</option>
        <option value="Radio-50">Wyoming</option>
        <option value="Radio-51">Washington DC</option>
      </select>
    </div>
    <div class="clear"></div>
    <div id="q27" class="q">
      <a class="item_anchor" name="ItemAnchor24"></a>
      <label class="question top_question" for="RESULT_FileUpload-24">Upload Resume</label>
      <div class=""><input type="file" name="RESULT_FileUpload-24" size="25" class="file_upload" id="RESULT_FileUpload-24" title=""
          accept=".avi,.bmp,.doc,.docx,.gif,.jpeg,.jpg,.mp3,.mp4,.mpeg,.mpg,.pdf,.png,.ppt,.pptx,.txt,.wav,.wmv,.xls,.xlsx,.zip"><br>
        <div class="file_upload_files"></div>
        <div class="file_upload_info"></div>
      </div>
    </div>
    <div class="clear"></div>
    <div id="q31" class="q full_width">
      <a class="item_anchor" name="ItemAnchor25"></a>
      <div class="segment_header" style="background:#BAC332;width:auto;text-align:Left;">
        <h1 style="font-size:20px;padding-bottom:10px;padding-top:10px;">Equal Opportunity Employer Statement</h1>
      </div>
    </div>
    <div class="clear"></div>
    <div id="q33" class="q full_width">
      <a class="item_anchor" name="ItemAnchor26"></a>
      <div class="full_width_space">
        <div><em>Information provided is for immigration purposes. Connetics USA is an equal opportunity employer encouraging diversity in the workplace. All qualified applicants will receive consideration for employment without regard to citizenship
            status, race, immigration status, national origin, gender, age, religion, disability, sexual orientation, veteran status, or marital status. Connetics USA offers a range of immigrant and non-immigrant visa sponsorship for qualified
            applicants needing such assistance. Connetics is an industry leader in international nursing recruitment. Our expert team will support you through each step of the application process.</em></div>
      </div>
    </div>
    <div class="clear"></div>
    <div id="q32" class="q full_width">
      <a class="item_anchor" name="ItemAnchor27"></a>
      <div class="segment_header" style="background:#BAC332;width:auto;text-align:Left;">
        <h1 style="font-size:20px;padding-bottom:10px;padding-top:10px;">Privacy Policy</h1>
      </div>
    </div>
    <div class="clear"></div>
    <div id="q34" class="q full_width">
      <a class="item_anchor" name="ItemAnchor28"></a>
      <div class="full_width_space">
        <div><em>Connetics USA respects the privacy of applicants and is committed to complying with the privacy laws in every country in which we recruit and hire applicants, including the General Data Protection Regulation in the European Union.
            Connetics USA's Applicant and Prospective Employee Privacy Policy is intended to inform applicants about how the personal information Connetics USA processes about each will be handled and protected by Connetics. Learn more at
            conneticsusa.com/privacy-policy</em></div>
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Text Content

subject_line


GENERAL INFORMATION


First Name *
Last Name *

Email *

Mobile Phone *
Date of Birth *  +

Citizenship *

Country of Birth * Afghanistan Albania Algeria Andorra Angola Antigua and
Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas, The
Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia
and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burma Burundi
Cambodia Cameroon Canada Cabo Verde Central African Republic Chad Chile China
Colombia Comoros Congo, Democratic Republic of the Congo, Republic of the Costa
Rica Cote d'Ivoire Croatia Cuba Curacao Cyprus Czechia Denmark Djibouti Dominica
Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea
Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia, The Georgia Germany
Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Holy See
Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel
Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, North Korea, South
Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein
Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali
Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco
Mongolia Montenegro Morocco Mozambique Namibia Nauru Nepal Netherlands New
Zealand Nicaragua Niger Nigeria North Korea Norway Oman Pakistan Palau
Palestinian Territories Panama Papua New Guinea Paraguay Peru Philippines Poland
Portugal Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint
Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia
Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten Slovakia Slovenia
Solomon Islands Somalia South Africa South Korea South Sudan Spain Sri Lanka
Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania
Thailand Timor-Leste Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan
Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay
Uzbekistan Vanuatu Venezuela Vietnam Yemen Zambia Zimbabwe
Current Country of Residence * Afghanistan Albania Algeria Andorra Angola
Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan
Bahamas, The Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan
Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso
Burma Burundi Cambodia Cameroon Canada Cabo Verde Central African Republic Chad
Chile China Colombia Comoros Congo, Democratic Republic of the Congo, Republic
of the Costa Rica Cote d'Ivoire Croatia Cuba Curacao Cyprus Czechia Denmark
Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador
Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia, The
Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti
Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland
Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, North Korea,
South Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya
Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia
Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia
Moldova Monaco Mongolia Montenegro Morocco Mozambique Namibia Nauru Nepal
Netherlands New Zealand Nicaragua Niger Nigeria North Korea Norway Oman Pakistan
Palau Palestinian Territories Panama Papua New Guinea Paraguay Peru Philippines
Poland Portugal Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia
Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi
Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten Slovakia
Slovenia Solomon Islands Somalia South Africa South Korea South Sudan Spain Sri
Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan
Tanzania Thailand Timor-Leste Togo Tonga Trinidad and Tobago Tunisia Turkey
Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United
States Uruguay Uzbekistan Vanuatu Venezuela Vietnam Yemen Zambia Zimbabwe







EDUCATION & WORK EXPERIENCE


Are you currently working (or have you been working within the past year) as a
registered nurse in a hospital setting? *

Yes No


Do you have 1 year RN experience in a Hospital or Home Health setting? *

Yes No


What is your current specialty? * Not Applicable Acute Medical Unit ACUTE
SURGICAL ONCOLOGY Ambulatory Blood Bank Burns and Plastics Cardiology Casualty
Cath Lab Certified Nursing Aide (CNA) Coronary Care Unit (CCU) CVICU Day Surgery
Dialysis Endoscopy ER ER - Pedia Geriatric HDU Healthcare Aide (HCA) Hematology
Hemodialysis Home Care Home Health ICU ICU - Cardiac ICU ICU - CVICU ICU - MICU
ICU - Neuro ICU ICU - NICU ICU - PICU ICU - SICU L & D Long-term Care (LTC) Med
/ Surg Medical Medical & Surgical ICU Medical Technologist (MT / MedTech) Need
Experience Neuro- Rehab Neurology New Grad Not Applicable Nursery OB - Gyne
Occupational Therapist (OT) Onco / Hema Oncology OPD OR OR - CVOR OR -
Ophthalmology OR-PACU OR/ Day Surgery Orthopedic Other PACU Paediatric Cardiac
Medical & Surgical ICU Palliative Care PCU Pedia Pediatric OR Personal Support
Worker (PSW) Physical Therapist (PT) Post - Partum Private Duty Nurse Psych /
Mental Health Radiology Rehab SBCU School Nurse Step Down Unit Surgical
Telemetry Trauma ICU Urgent Care

What is your current profession? * Not working Registered Nurse (RN) Licensed
Practical Nurse (LPN) Registered Practical Nurse (RPN) Certified Nursing
Assistant (CNA) Healthcare Aide (HCA) Medical Doctor (MD) Medical Technologist
(MT / MedTech) Occupational Therapist (OT) Physical Therapist (PT) Other

Have you passed the NCLEX? *

Yes No


Do you have a Bachelor's Degree or Master's Degree in Nursing? *

Yes No


Have you passed the English exam (IELTS/TOEFL)? * Pass Fail Expired No Scheduled
Waiting for results N/A TOEFL IBT Rescore Pending Re-take

Do you have a previously-filed employment-based Green Card (I-140) petition? *

Yes No


Has your previously filed Green Card (I-140) petition been approved? *

Yes No


What is your preferred US State of employment? (1st choice) Any Alabama Alaska
Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii
Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland
Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada
New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio
Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee
Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Washington DC

What is your preferred US State of employment? (2nd choice) Any Alabama Alaska
Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii
Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland
Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada
New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio
Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee
Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Washington DC

What is your preferred US State of employment? (3rd choice) Any Alabama Alaska
Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii
Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland
Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada
New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio
Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee
Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Washington DC

Upload Resume







EQUAL OPPORTUNITY EMPLOYER STATEMENT


Information provided is for immigration purposes. Connetics USA is an equal
opportunity employer encouraging diversity in the workplace. All qualified
applicants will receive consideration for employment without regard to
citizenship status, race, immigration status, national origin, gender, age,
religion, disability, sexual orientation, veteran status, or marital status.
Connetics USA offers a range of immigrant and non-immigrant visa sponsorship for
qualified applicants needing such assistance. Connetics is an industry leader in
international nursing recruitment. Our expert team will support you through each
step of the application process.



PRIVACY POLICY


Connetics USA respects the privacy of applicants and is committed to complying
with the privacy laws in every country in which we recruit and hire applicants,
including the General Data Protection Regulation in the European Union.
Connetics USA's Applicant and Prospective Employee Privacy Policy is intended to
inform applicants about how the personal information Connetics USA processes
about each will be handled and protected by Connetics. Learn more at
conneticsusa.com/privacy-policy


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