LTACH RN Application Survey RN LTACH Application Please fill out the form below: First Name: Last Name: City Applying For: State Applying For: -- Select a State -- 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 Do you have at least 1-2 years of critical care experience as an RN and are comfortable working around high acuity patients that are on drips, trachs, or vents? Yes No Have you worked with Select Specialty before? Yes No If yes, please provide when and where you worked and your rehire eligibility status: Email: Phone: First 4 digits of your birthdate (e.g., March 22 = 03/22): Would you like to proceed and be submitted? Yes No