LAB TECH
PROFESSIONAL PROFILE

[HRule Image]
If you prefer, you can print a form to fax or mail.
[HRule Image]

     Last Name: 
    First Name: 
Middle Initial: 
Profession:
MT             Years Experience: 
MLT            Years Experience: 
HISTO          Years Experience: 
CYTO           Years Experience: 
PHLEB          Years Experience: 
LAB ASSISTANT  Years Experience: 

Instructions:  Complete only those items that apply to your profession.

SPECIALTIES: [Please check all areas you are qualified and experienced to work.]

- GENERAL    - BLOOD BANK    - CHEM    - MICRO    - X-RAY
- OTHER:    - OTHER: 
- OTHER:    - OTHER:

PROFESSIONAL LICENSURE:

License #:  State:    License #:  State:    
License #:  State:    License #:  State:

CERTIFICATIONS:

- ASCP   - NCA   - AMT   - HEW   - CT   - HT
- Other:   - Other: 
- Other:   - Other:
CHICKEN POX STATEMENT:
Yes, I have had chicken pox.
No, I have not had chicken pox.		 FACILITY/SPECIALTY PREFERENCE:
1st Choice: 
2nd Choice: 
3rd Choice:
Press 'Register' to send the form to us and proceed to the Skills Proficiency Checklist.
Date: 
Phone / Email:
 
© 2008 Rapid Temps, Inc. • 1-800-581-4846 • Privacy Policy