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

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Applicant Profile

for Laboratory and Ancillary Services Professionals

Please complete the following applicant profile.
Fields in bold type are required.
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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
Certifications (check all that apply)	MT MLT Cytology CMA	Phlebotomy Histology Bloodbank
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 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