Personal Information:
How were you referred to @WORK Medical Services:
First, Middle, Last Name
(exactly as appears on government identification):
Present Street Address:
City:
State:
Zipcode
Home Telephone:
Work Telephone:
Cell Telephone:
Email Address:
Have you ever worked with @WORK before: No  Yes
If yes, Name: Office Location
Approximate Month/Year:
Reason for Leaving:
Have you ever worked with an agency before: No  Yes
If yes, Agency Name: Office Location
Approximate Month/Year:
Reason for Leaving:
   

Availability - Job Information
List your Medical Specialties:
Expected Wage?
Are you legally authorized to work in the United States? No  Yes
Can you perform the essential functions of the job for which you are applying? (see job description) No  Yes
Date Available for Work?
Check all for which you are willing to work 8 hour shifts 12 hour shifts Overtime
  Weekends 1st shifts 2nd shifts
  3rd shifts
What regions or facilities do you prefer?
List any facilities for which you will not work:
   

PLEASE CHECK PREFERRED SCHEDULE:
Hours Available Monday Tuesday Wednesday Thursday Friday Saturday Sunday TYPE OF
ASSIGNMENT
DESIRED:
Place a CHECK
MARK on each
day, if you have
NO RESTRICTIONS:		 Per Diem
 13 Week
 Temp/Hire
OR: "I am
available to work
on this day from:"
(list start & end
times)
to
to
to
to
to
to
to

LENGTH OF
TIME THIS
SCHEDULE
IS
EFFECTIVE:
               
 

Education/Skills Overview
Type:
Name & Address of Institution:
Major/Minor
Last Year Attended:
Graduated: No  Yes
Degree:
Medical Degree:
Certificate/License/Specialty:
Expiration Date:
Certificate/License/Specialty:
Expiration Date:
Certificate/License/Specialty:
Expiration Date:
Certificate/License/Specialty:
Expiration Date:
Certificate/License/Specialty:
Expiration Date:
   

Current Employment
Current Employer, if more than one, list
briefly in comments section:
Dates Worked to
Describe Your Position/Duties:
Starting Salary:
Ending Salary:
Status of Job Assignments:
Facility/Employer
Address:
City, State, Zipcode
Departments Worked:
Supervisor Name & Title:
Supervisor Phone Number:
Supervisor Email Address:
List Facility/Setting:
Explain Any Periods Between Jobs:
Comments:
 

What three co-workers do you feel would be interested in working with us?
Name:
Home Phone:
Work Phone:
Name:
Home Phone:
Work Phone:
Name:
Home Phone:
Work Phone:

What to bring to the interview: (we will schedule your interview and advise appointment date & time)

1) Current Resume;
2) Two forms of identification
3) Names & Phone numbers of three references (must be supervisor)
4) Verification of TB, MMR, and Hep B
5) Copies of Certifications & Licensed

 

3716 Willow Ridge Road, Lexington, KY 40514, Fax: (859) 296-0625

Office Hours:
8:00am-5:00pm, Monday-Friday,
with 24 hour voice mail and pager system.

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