MEDRelief Staffing ~ Candidates - Applicant Profile: Staffing services for diagnostic, imaging, and healthcare professionals - radiology, nursing, respiratory, laboratory

Earn CE tuition credits through our
Educational Partnership.

Click on below for more details.

Applicant Profile

for Imaging Professionals

Please complete the following applicant profile.
Fields in bold type are required.
Please click the button at the end of the form to send this form to us or you may print it and fax it to the number below.

**Please call us if you have submitted a profile via e-mail in the last 10 days and have not received a confirmation.**

800.342.6704	[toll-free telephone]
866.250.5321	[toll-free fax]


First Name	Last Name
Permanent Address
City		State	Zip
Current Address (if different from above)
City		State	Zip
Daytime Phone	XXX-XXX-XXXX
Evening Phone	XXX-XXX-XXXX
E-mail Address
Best time to contact you
ARRT Registry Number
State & License Number
Additional Licenses
Certifications (check all that apply)	Diagnostic OR/ER CT Mammo MRI Nuclear Medicine RDMS RDCS	RVT Cath Lab LMRT Special Procedures Rad Therapy Densitometry LMRT
Current Experience (check only one)	Less than 1 year 1-2 years 2-5 years 5-10 years More than 10 years
Current Employer
Criminal History	Have you ever been convicted of a felony or a crime? Yes No
	If yes, please explain:
Interested in (check all that apply)	Local (Houston area) Full-Time Long-Term (13+ Wks) Temp to Perm	Travel (outside Houston) Part-Time Short-Term
Shift Preferences (check all that apply)	Days Weekends	Nights Holidays
Availability	Now	Date
Travel Preferences	1st Travel Choice	2nd Travel Choice
	Geographic preference
	Traveling with pets? Yes No
	If yes, please specify type and weight (in pounds): lbs.
Referral Source (check all that apply)	Newspaper Friend Catalog Postcard AHEC class Web site E-mail Ad in ADVANCE Newsmagazine Ad in ASRT Scanner Ad in Radiology Management Ad in Texas Hospitals Ad in Texas Family Physician Search engine ~ please specify: Link from another site ~ please specify: Medical facility/medical journal ~ please specify:
Additional Comments or Questions