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: |
| - ASCP
- NCA - AMT
- HEW
- CT - HT |
| Other:
|
| Other:
|
| Other:
|
| Other:
|
| CHICKEN POX STATEMENT: |
FACILITY/SPECIALTY
PREFERENCE: |
I
have had chicken pox.
Yes
No
|
1st Choice:
2nd Choice:
3rd Choice: |
|
Phone: |
Email: |
Date: 
|
 - Required field |
|
|
