Last Name: 
    First Name: 
Middle Initial: 
 

RRT   Years Experience: 
CRTT  Years Experience: 
POLY  Years Experience: 
EEG   Years Experience: 
R-EEG Years Experience: 

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

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

- NICU     - PICU     - ICU     - MICU     - SICU

- OTHER:    - OTHER: 

- OTHER:    - OTHER: 

PROFESSIONAL LICENSURE:

License #:  State:    License #:  State:    

License #:  State:    License #:  State:    

CERTIFICATIONS:

- BLS/CPR   - ACLS   - NALS   - PALS

- Other:   - Other: 

- Other:   - Other: 

1st Choice: 
2nd Choice: 
3rd Choice: 

© Rapid Temps, Inc., rev 12-99

Press 'Register' to send the form to us and proceed to the Skills Proficiency Checklist.

Phone / Email: 

Date: