![[HRule Image]](../images/div.gif){kind=small}
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: __________________________________ |
Profession:
___ RRT Years Experience: ______ ___ CRTT Years Experience: ______ ___ POLY Years Experience: ______ ___ EEG Years Experience: ______ ___ R-EEG Years Experience: ______ |
INSTRUCTIONS:
1. Please print or type clearly.
2. 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: _______________________
PROFESSIONAL LICENSURE:
License #: ____________ State: ____ License #: ____________ State: ____
License #: ____________ State: ____ License #: ____________ State: ____
CERTIFICATIONS:
___ BLS/CPR ___ ACLS ___ NALS ___ PALS
Other: _________________________ Other: _________________________
Other: _________________________ Other: _________________________
| CHICKEN POX STATEMENT: o Yes, I have had chicken pox. o No, I have not had chicken pox. Initial: Date: |
FACILITY/SPECIALTY PREFERENCE: 1st Choice: _______________________ 2nd Choice: _______________________ 3rd Choice: _______________________ |
Signature: _______________________ Date: ____________________
* Reminder: include photocopies of both sides of all
professional licenses, registrations, and certifications.
Phone / Email:
© Rapid Temps, Inc., rev 12-99
Please complete the Skills Proficiency Checklist to complete your registration.
