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PRE-EMPLOYMENT DATA SHEET

 
Contact Information:
         
First Name:   Last Name:  
         
Address 1:   City:  
Address 2:   State:  
      Zip Code:  
         
Home Phone:  
Alternate Phone:  
Email:  
           
Credential: (Check all that apply)         
           
  CRT    RRT GRT RCP  
           
  CPFT RPFT Student    
           
  Basic Life Support (BLS) ACLS PALS  
           
  Others:  
           
  Clinical Experience Years:  
           
  Acute Care   Long-Term Acute Care (LTAC)    
       
  Home Care Critical Care (ICU)  
       
           
Shift Preference  
           
  Days Nights Weekends    
           
  8 Hour Shifts   12 Hour Shifts    
           
  Full-time Part-time PRN    
           
  Other Availability: