RN · LPN · CNA Application

Join Success Nurse Agency Inc

Complete the form and upload your credentials. Most applicants are placed on a shift within 7 days. We pay the highest rates in Chicagoland and connect with the American Heart Association to keep your BLS, ACLS and PALS credentials current.

Applying as a Respiratory Therapist?Use the RT application →

Personal Information

Full legal name *

Date of birth *

Email *

Phone *

Street address *

City *

State *

ZIP *

Licensing & Experience

Role *

Years of experience *

License number *

License state *

Expiration *

Specialties (ICU, Med-Surg, ER, LTC…)

Employment Classification (W-2 or 1099)

Important — read before selecting

Your W-2 vs 1099 status can only be changed once per year. After you choose, your next change will be allowed on this same date next year. Pick carefully — this affects your taxes, benefits eligibility, and how you're paid.

I understand my W-2/1099 status is locked for 365 days after approval and can only be changed once per year on the anniversary of this selection.

Current Certifications

Check what you currently hold. We connect with the American Heart Association to keep your BLS, ACLS and PALS credentials current.

Availability

Shift preference

Earliest start date

Professional references

Anything else we should know?

Upload Documents

Accepted: PDF, JPG, PNG, HEIC. Max 15MB per file. All uploads are private and encrypted.

Nursing License (RN/LPN/CNA) *

Current state license — front & back

Government-Issued Photo ID *

Driver's license or passport

Social Security Card *

For payroll & background check

Resume / CV *

Most recent work history

Nursing Diploma / Transcript

Proof of education

BLS Certification

American Heart Association preferred

ACLS Certification

If applicable

PALS Certification

If applicable

CPR Certification

If separate from BLS

Immunization Records *

MMR, Varicella, Hep B, Flu, Tdap

TB Test / Chest X-Ray *

Within the last 12 months

COVID-19 Vaccination Record

Card or digital record

Annual Physical Exam

Within the last 12 months

Background Check Authorization

Disclosure & Authorization — Fair Credit Reporting Act (FCRA)

Success Nurse Agency Inc ("the Company") may obtain a "consumer report" and/or an "investigative consumer report" about you from a consumer reporting agency for employment purposes. These reports may include information about your character, general reputation, personal characteristics, mode of living, criminal history, motor vehicle records, education, previous employment, professional licenses and certifications, drug testing results, workers' compensation records (where legally permissible), and other information necessary to evaluate your suitability for placement as a healthcare professional.

Reports may be prepared and delivered by a third-party Consumer Reporting Agency (CRA). You have the right, upon written request made within a reasonable time, to request additional disclosures regarding the nature and scope of the investigation, a written summary of your rights under the FCRA, and a copy of any report obtained.

This authorization remains valid for the duration of your engagement with the Company and any renewal or reassignment, to the extent permitted by law. A photocopy or electronic copy of this authorization is as valid as the original.

California, Minnesota, Oklahoma applicants: Check here to receive a free copy of any consumer report obtained about you.

Full legal name (as it appears on your ID) *

Any other names used (maiden, alias, prior legal name)

Social Security Number *

DL State

Driver's license #

I acknowledge that I have received and read the FCRA disclosure above, and a summary of my rights under the Fair Credit Reporting Act.I authorize Success Nurse Agency Inc and its designated consumer reporting agency to obtain a background check, including criminal history, employment, education, license verification, motor vehicle, and drug testing records, for employment purposes.

Signature *

Sign below with your finger (mobile) or mouse. This signature has the same legal effect as a handwritten one.

Draw your signature above

Signed on July 24, 2026

By submitting this application I certify that the information and documents provided are true and accurate. I authorize Success Nurse Agency Inc to verify my credentials, run a background check, and contact the references I've listed.

Our recruiting team responds within 24 hours.