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PHYSICIANS

ADVANCED PRACTICE

PHARMACY

THERAPY

RADIATION ONCOLOGY

LABORATORY

IMAGING

RESPIRATORY

EMPLOYERS

Allied Application

Please fill out the following secure online application as completely as possible. When completed hit the submit button at the bottom of the page.
Identifying Information
First Name:
Middle Name:
Last Name:
SSN# (optional):
Current Address:
City/ State/ Zip:
Permanent Address:
City/ State/ Zip:
Home Phone:
Work Phone:
Cell Phone:
Email Address:
Best Time/Day to Reach:
Birthdate:
Other names you have
been employed under:
NPI # (optional):

Discipline:
Other/Sec. Discipline:
Date Available:
Other:
 
 
Emerg. Contact:
Relationship:
Phone:
Address:
City/State/Zip
    
Are you a U.S. citizen:
 Yes No  
If no, can you submit verification of your legal right to work in the U.S: Yes No
How did you hear about us:
Professional License & Certification Information
License Type:
License Number:
State/Province:
Exp Date :
License Type:
License Number:
State/Province:
Exp Date :
               
Cert. Board:
Cert. Date::
Cert. Board:
Cert. Date::
Cert. Board:
Cert. Date::
Cert. Board:
Cert. Date::
Certifications
ACLS Exp Date   ARRT (VIT) Exp Date   NRP Exp Date
ARDMS (RVT) Exp Date ASCP (MLT) Exp Date OTR Exp Date
ARDMS (Sonography) Exp Date   ASCP (MT) Exp Date   PALS Exp Date
ARRT (CIT) Exp Date   BLS Exp Date   PT Exp Date
ARRT (CT) Exp Date   CMD Exp Date   PTA Exp Date
ARRT (MAMMO) Exp Date   COTA Exp Date   RCIS (CIT) Exp Date
AART (MRI) Exp Date   CRT Exp Date   RCIS (VIT) Exp Date
AART (NMT) Exp Date   EEG Exp Date   RDCS Exp Date
AART (Rad Tech) Exp Date   NBRC Exp Date   RPSGT Exp Date
AART (Rad Therapist) Exp Date   NALS Exp Date   RRT Exp Date
AART (Sonography) Exp Date   NMTCB (NMT) Exp Date   SLP Exp Date
ASHA Exp Date   NBCOT Exp Date        
Education
School Name/Institution::
City/State:
Date of Graduation:
Degree/Certifications:
Honors Received:
 
       
School Name/Institution::
City/State:
Date of Graduation:
Degree/Certifications:
Honors Received:
 
       
School Name/Institution::
City/State:
Date of Graduation:
Degree/Certifications:
Honors Received:
 
Employment History
Facility/Employer Name::
Unit/Floor/Dept.
City/State/Zip:
    
Start Date::
End Date:
Reason for Leaving:
Position Held:
Patient Load:
Unit Specialty:
Travel Assignment:
 Yes No
Travel Company:
Local Staff Agency:
       
Facility/Employer Name:
Unit/Floor/Dept.
City/State/Zip:
    
Start Date::
End Date:
Reason for Leaving:
Position Held:
Patient Load:
Unit Specialty:
Travel Assignment:
 Yes No
Travel Company:
Local Staff Agency:
       
Facility/Employer Name:
Unit/Floor/Dept.
City/State/Zip:
    
Start Date:
End Date:
Reason for Leaving:
Position Held:
Patient Load:
Unit Specialty:
Travel Assignment:
 Yes No
Travel Company:
Local Staff Agency:
       
Facility/Employer Name::
Unit/Floor/Dept.
City/State/Zip:
    
Start Date::
End Date:
Reason for Leaving:
Position Held:
Patient Load:
Unit Specialty:
Travel Assignment:
 Yes No
Travel Company:
Local Staff Agency:
       
Other
Have you ever been convicted of a crime other than a minor traffic violation? : Yes No
If yes, please explain:
 
Driving under the influence is not considered a minor traffic violation. Exceptions due to state employment law: Convictions that have been sealed, expunged, or eradicated and California Health & Safety Code §§11357 (b) & (c), 11360(c), 11364, 11365, 11550 marijuana related convictions over 2 years old, should not be revealed.
 
Have you ever had your license or certification investigated, suspended, or revoked? Yes No
If yes, please explain:
 
Have you ever been named as a defendant in a liability action? Yes No
If yes, please explain:
 
Do you have any restrictions that would prevent you from performing essential functions in the position you are applying for? Yes No
If yes, please explain:
 
Do you have at least one year of working experience in your discipline/specialty? Yes No
If no, please explain:
 
Professional Society Membership or Fellowship/Board Certification? Yes No
 
Other than those circumstances noted above, is there anything in your personal or professional background that may surface during our credentials verification process that may be construed as derogatory or negative? Yes No
Please list a minimum of three professional references with whom you have worked in the past two years and who will confirm a more detailed reference of your specific medial abilities:
1. Name:
Position:
Association
Phone:
Facility:
City/State:
Zip
Email:
 
 
 
 
2. Name:
Position:
Association
Phone:
Facility:
City/State:
Zip
Email:
 
 
 
 
3. Name:
Position:
Association
Phone:
Facility:
City/State:
Zip
Email:
Resume
Attach Your CV
 
I attest that all statements in this application are true and accurate to the best of my knowledge. I understand that any falsification could lead to disciplinary action and/or termination of employment. I authorize Next Medical Staffing to contact past employers and references in order to verify the information I have provided. I release all such persons from liability for furnishing said information. I authorize Next Medical Staffing to release a copy of this application and any medical information which may be relevant to my employment to their client facilities. I agree to hold confidential any client or job opportunities introduced to me by Next Medical Staffing, and agree not to accept assignment or engage directly with any client introduced by Next.

 

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