Online Profile & Affirmative Action Form Page 2
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4State & License Number:
State
License #
Additional Licenses:
State
License #
State
License #
Other ~ please specify:
Current Experience (check only one):
1-2 years
2-5 years
5-10 years
More than 10 years
Criminal History:
Have you ever been convicted of a felony or a crime?
Yes
No
Interested (check all that apply):
Local
Contract
PRN
Temp-to-Hire
Shift Preferences (check all that apply):
Days
Nights
Weekends
Holidays
Availability:
Now
Date:
Would You Like to Travel?
Yes
No
Referral Source (check all that apply):
MEDRelief Employee (Name of employee):
Friend
(Name of friend):
Online Catalog
Postcard
AHEC class (Please specify class):
E-mail
Social Media (Please specify; ex. Facebook or Twitter):
CareerBuilder
Search engine:
Link from another site ~ please specify:
Medical facility/medical journal ~ please specify:
Other:
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Parent category: Business