Application form – Contract Submit Your Profile For Contract Please mention NA if it does not apply to you SCREENING QUESTIONS RESPONSES ATTACHMENTS Basic Information Full Legal Name - Along with Middle Name Phone Number (Mobile/Home) Primary Email ID Current Location Work Authorization (Green Card or Citizen) Date of birth: MM/DD/YY SSN: (last four digits) (Full SSN might be required depending on need of the clients) Professional Information/Preferences Are you currently on Assignment? (Y/N) If, is it full-time or a contract Is it Full Time or Contract? How many days Notice period required to serve if working permanent? Current Contract End Date When are you looking to start the next assignment? Are you requesting any time off during the next 13 weeks assignment? (Any RTO not mentioned will not be approved and this can lead to cancelation of the assignment) Shift interested in: (Nights/Days/Evenings) Are you open for any other shift apart from mentioned above Shift hours interested in 8/10/12 hours Are you open for any other shift hours apart from mentioned above Preferred Time for the phone interview: Higehst Patient ratio: Trauma level worked in (I, II, III, IV) EMR Charting system: Equipment/Tools/Machines used (For Lab/Imaging Professionals) Please share recent and updated resume Education Information Highest related Completed Education (Please do not mention the ongoing education) College/University Name Please attach copy of Transcript/Degree/Diploma Certifications and Licenses Active License & Number (State license name) BLS ACLS PALS NRP TNCC/AWHONN/ENPC/Any other speciality Certification CST/Sterile/ARDMS/ARRT/ASCP/CMA /Any other professional Certification Travel Information How are you going to travel to the facility? (Car/Flight) Are you travelling alone for the assignment? Do you have sufficient Funds to manage the expenses for your travel/stay for the first week of the contract? 2 Professional references within last 1 year Name of Supervisor Facility worked with Title Email ID Phone Number 2nd Reference Name of Supervisor Facility worked with Title Email ID Phone Number Immunizations Do you have all shots for Covid including boosters? Have you already taken your Flu shot MMR Vericella Physical Fit Test TDAP TB/TSPOT/TB-gold/Q-gold SSN Card (after the offer) DL (After the offer)
