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| First Name |
Last Name |
| Address |
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| City |
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State |
Zip |
| Daytime Phone |
XXX-XXX-XXXX |
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| Evening Phone |
XXX-XXX-XXXX |
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| E-mail Address |
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Imaging Professionals
(select all that apply Ctrl-Click or Cmd-Click on Mac) |
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Other: Please specify: |
Nursing Professionals and Ancillary Professionals
(select all that apply Ctrl-Click or Cmd-Click on Mac) |
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Nursing Specialty
(select all that apply Ctrl-Click or Cmd-Click on Mac) |
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| State & License Number |
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| Additional Licenses |
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Other: Please specify: |
Current Experience
(check only one) |
Less than 1 year
1-2 years
2-5 years
5-10 years
More than 10 years |
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| Criminal History |
Have you ever been convicted of a felony or a crime?
Yes No |
| Interested (check all that apply) |
Local (Houston)
Contract
PRN
Temp-to-Hire
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| Shift Preferences (check all that apply) |
Days
Weekends |
Nights
Holidays |
| Availability |
Now |
Date |
| Would You Like to Travel? |
Yes |
No |
| Referral Source (check all that apply) |
MEDRelief Employee: Name
Friend: Name
Online Catalog
Postcard
AHEC class
Other ~ please specify
E-mail
On Facebook
On Twitter
On LinkedIn
On CareerBuilder
Search engine: Google Firefox
Other ~ please specify:
Link from another site ~ please specify:
Medical facility/medical journal ~ please specify:
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| Additional Comments or Questions |
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AFFIRMATIVE ACTION QUESTIONNAIRE
Advanced Health Education Center, Ltd is a Government contractor and is subject to affirmative action obligations pursuant under Executive Order 11246 (minorities and females, ), the Rehabilitation Act of 1973 (individuals with disabilities) and the Vietnam-Era Veterans Readjustment Assistance Act of 1974 ("VEVRAA" - covered veterans).
Our company is requires to report sex and race/ethnic origin of applicants for employment. Applicants are considered for all positions without regard to race, color, religion, gender, national origin, age, marital or veteran status, or the presence of a non-job related medical condition or disability. The information requested below is voluntary; failure to provide the information will not jeopardize or adversely affects consideration of your employment. Your cooperation is appreciated. The information obtained will be kept confidential and may only be used in accordance with applicable laws. When data is reported, it will not identify any specific individual. |
Print Name:
Last, First, Middle |
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| Date |
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| Date of Birth (m/d/yyyy) |
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| Position sought |
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| Job Location |
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GENDER:
Please check one: |
Male |
Female |
| ETHNIC GROUP: |
Hispanic / Latino (All persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race.) |
Non Hispanic / Latino (If this is checked, please select from the racial groups below) |
RACIAL GROUPS:
(If Non-Hispanic/Latino was selected above, please check one) |
American Indian / Alaskan Native (All persons having origins in any of the original peoples of North or South America, and who maintain cultural identification through tribal affiliation or community attachment.)
Asian (All persons having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.)
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Black / African American (All persons having origins in any of the Black racial groups of Africa.)
Native Hawaiian / Other Pacific Islander (Any persons having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.)
White (All persons having origins in any of the original people of Europe, North Africa, or Middle East.)
Two or More Races (All persons who identify with more than one of the above races.) |
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VETERANS:
(A veteran of the US military, ground, naval or air service): Please check all that apply: |
Disabled Veteran (1. A veteran who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of VA. 2. A person who
was discharged or released from active duty because of a service-connected disability.)
Other Protected Veteran (A veteran who served on active duty during a war or in a campaign or expedition for which a campaign badge has been authorized.
)
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Armed Forces Service Medal Veteran (All persons having origins in any of the Black racial groups of Africa.)
Recently Separated Veteran (A veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty.)
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| Most Recent Discharge/Release Date: |
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