Please indicate appropriately for the following:

OSHA Training: Yes   No Date:  _________   HIPPA:  Yes   No Date:    ________

HB Vaccines: Yes    No  Dates: ______   ______    ______

Bilingual? ________________Language?  ___ Fluent  ___ Speak  ___ Read  ___ Write

ARRT Number:   IV Certificate 

No.CMA/RMA No.:  RN License No.: Exp.

PA Cert. No.:  LVN License No.: Exp. ______

MLT: ASCP MLT/MT No:

COA: COT:

Position applying for:

What do you feel best qualifies you for this position?

Other types of positions for which you are qualified?

What areas (s) of the city will you work? List in order of preference, 1=1^st choice, 2=2^nd choice, etc.:  Any    NW       NE      NC/Stone Oak        SW        SE       DT

Please describe your ideal position including hours, benefits, and salary requirement:

Salary Requirement:

Please list all physicians’ offices, groups and clinics where you currently or recently have applied:

Anything of importance that you would like to mention?

Notice Required for an interview?  To take assignment?

Any specialties you want to avoid?

Any specialties you have experience in?