| Print this form and fax or mail: Fax to: (505) 797-3822 Mail to: 5150 San Francisco RD NE Albuquerque, NM 87109 |
Last Name:
First Name:
Middle Initial:
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Profession: RRTYears Experience CRRT Years Experience POLY Years Experience RPSGT Years Experience |
INSTRUCTIONS:
1. Please print or type clearly.
Complete only those items that apply to your profession.
SPECIALTIES: [Please check all areas in which you are qualified and experienced to work.]
NICU PICU ICU MICU SICU
Other: Other:
Other: Other:
EXPERIENCE: [Please check all areas in which you have experience.]
ER MED/SURG RR ICU/CCU STEP DOWN TCU REHAB HOME HEALTH L & D POST PARTUM NURSERY PEDIATRICS OR CATH LAB MONITOR TECH PSYCH Other: Other: Other: Other:PROFESSIONAL LICENSURE:
License #: State: License #: State: License #: State: License #: State:CERTIFICATIONS:
- BLS/CPR - ACLS - NALS - PALS - Other: - Other: - Other: - Other:
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CHICKEN POX STATEMENT: - Yes, I have had chicken pox - No, I have not had chicken pox
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FACILITY/SPECIALTY PREFERENCE 1st Choice: 2nd Choice: 3rd Choice: |
Submitted by: Date:
Phone / Email:
Reminder: include photocopies of both sides of all professional licenses, registrations, and certifications.
©Rapid Temps, Inc, rev 12-99
Please complete the Skills Proficiency Checklist to complete your registration.
