Last:              First:              Credentials:  

Registry #.  

Home Phone #:               Cell Phone #:  

E-mail:  

Address:   

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How many years’ of experience do you have in ultrasound not including your clinical experience at school?  

Check all the clinical environments that you are comfortable working in:
             University Teaching Hospitals
             Community Hospitals
             Private Offices
             Other   

Previous Employer:  

Phone #:      Ext:  

E-mail:  

Address:   

City:                Please Select ---------------------- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist. of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming            Zip:  

Description Job Duties:
           
 

Employed from:			To:
	Month/Year			Month/Year

May we contact your previous employer?		Yes		No
Have you ever been convicted of a crime other than a minor traffic violation? (If yes, attach a separate sheet with explanation).		Yes		No
Have any claims/suits been made against you within the last 5 years? (If yes, attach a separate sheet with explanation).		Yes		No
Have you ever been involved as a defendant in professional malpractice litigation? (If yes, attach a separate sheet with explanation).		Yes		No
Do you have any history of drug, alcohol or sexual abuse? (If yes, attach a separate sheet with explanation).		Yes		No

Skills Survey

Check all the procedures & ultrasound equipment that you are proficient with: