Today’s Date:
Available Date:
First Name:
Last Name:
Your Email:

Legal First Name (if different):
Legal Last Name (if different):
Permanent Address:
City, State, Zip:
Current Address (if different):
City, State, Zip:
US Social Security Number:
Cell Phone:
Alternate Phone:
Best Time to Call:
Referred By:
Emergency Contact Name:
Emergency Contact Phone:
Work Status: US CitizenPerm ResidentF-1 Visa HolderH-1 Visa Holder/Need H-1 VisaTN Permit HolderOther

School Name:
School Name:
City:
City:
State:
State:
Country:
Country:
Degree:
Degree:
Month Graduated:
Month Graduated:
Year Graduated:
Year Graduated:

Specialty:
Specialty:
Years Experience:
Years Experience:
Last Date Used:
Last Date Used:

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Specialty:
Specialty:
Years Experience:
Years Experience:
Last Date Used:
Last Date Used:

Certification:
Exp Date:
Certification:
Exp Date:
Certification:
Exp Date:
Certification:
Exp Date:
Certification:
Exp Date:
Certification:
Exp Date:

State:
License #:
Exp Date:
Compact: Yes

State:
License #:
Exp Date:
Compact: Yes

State:
License #:
Exp Date:
Compact: Yes

State:
License #:
Exp Date:
Compact: Yes

State:
License #:
Exp Date:
Compact: Yes

Select all EMR/EHR/Charting Systems you have experience with: CernerEpic (EpicCare, etc.)MeditechMcKesson (Horizon, etc.)SiemensGE Healthcare (Centricity, etc.)AllscriptsHealth ConnectOther

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Select all EMR/Charting Systems that you have been present for the implementations or conversion to: CernerEpic (EpicCare, etc.)MeditechMcKesson (Horizon, etc.)SiemensGE Healthcare (Centricity, etc.)AllscriptsHealth ConnectOther

Have you ever been convicted of a crime other than a minor traffic violation? YesNo    If yes, If yes, please explain:

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Have you ever been names as a defendant in a professional liability action? YesNo    If yes, If yes, please explain:

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Has action ever been taken against your professional license? YesNo    If yes, If yes, please explain:

Facility Name:
Employed From:
To:
City, State, Zip:
Position Held:
Specialty:
Shift Times:
Average Patient Ratio:
# of Beds in Unit:
# of Beds in Facility:
Reason for Leaving:
Clinical Reference:
Reference Phone #:
Can we contact reference? YesNo
Teaching Facility? YesNo

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Charge Experience? YesNo
Travel Assignment? YesNo
If Yes, what agency?

Facility Name:
Employed From:
To:
City, State, Zip:
Position Held:
Specialty:
Shift Times:
Average Patient Ratio:
# of Beds in Unit:
# of Beds in Facility:
Reason for Leaving:
Clinical Reference:
Reference Phone #:
Can we contact reference? YesNo
Teaching Facility? YesNo

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Charge Experience? YesNo
Travel Assignment? YesNo
If Yes, what agency?

Facility Name:
Employed From:
To:
City, State, Zip:
Position Held:
Specialty:
Shift Times:
Average Patient Ratio:
# of Beds in Unit:
# of Beds in Facility:
Reason for Leaving:
Clinical Reference:
Reference Phone #:
Can we contact reference? YesNo
Teaching Facility? YesNo

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Charge Experience? YesNo
Travel Assignment? YesNo
If Yes, what agency?

Employer:
Dates: (mth/yr-mth/yr)
If Travel Assignment/Per Diem work list agency name:
City, State:
Position:

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Employer:
Dates: (mth/yr-mth/yr)
If Travel Assignment/Per Diem work list agency name:
City, State:
Position:

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Employer:
Dates: (mth/yr-mth/yr)
If Travel Assignment/Per Diem work list agency name:
City, State:
Position:

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Employer:
Dates: (mth/yr-mth/yr)
If Travel Assignment/Per Diem work list agency name:
City, State:
Position:

---

Employer:
Dates: (mth/yr-mth/yr)
If Travel Assignment/Per Diem work list agency name:
City, State:
Position:

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Employer:
Dates: (mth/yr-mth/yr)
If Travel Assignment/Per Diem work list agency name:
City, State:
Position:

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Employer:
Dates: (mth/yr-mth/yr)
If Travel Assignment/Per Diem work list agency name:
City, State:
Position:

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Please explain any gaps in Work History, including Month and Year (to complete full 7 years):

I certify the information contained in this application is true, correct, and complete. I understand
that, if employed, false statements reported on this application may be considered sufficient cause
for dismissal.
Name:
Date: