Medlinx Consultants, Inc.

INSTRUCTIONS

Attach a current resume to completed application that covers all periods of time, from undergraduate school to present. Indicate month and year.
Provide a thorough explanation for every malpractice claim, suit, or incident you have EVER experienced. At minimum, this must include information on: type of care, procedure, moor allegations, end other pertinent information, such as the name and location of court, names of parties involved, and a brief description of the nature of the claim.

THIS COMPANY IS AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER
As anEqualOpportunity/Affirmative Action Employer. Medlinx consultants, Inc., does not discriminate in employment on the basis of Age, Gender, Race, Color, Religion, National Origin, Disability, Veteran Status or any other classification protected by Local, State, and Federal laws. Please omit any references (o organizations or activities that would indicate Race, Religion, Age, Gender, Sexual Orientation, National Origin or Ancestry, Disability, or Political Persuasion.

IDENTIFYING
INFORMATION

Last Name

First name

Middle name

Previous Surname

Profession

License
Certificate No.

Social Security Number

Home Phone

Work Phone

Are you a United States citizen? Yes No
1f no, what is our visa or alien registration status?

Cell Phone

Pager

In case of emergency,
notify: Name

Relationship to Applicant

Phone

Address

MAILING ADDRESS

Street

City

State

ZIP Code

OTHER
ADDRESS

Street

City

State

ZIP Code

Other Phone

AVAILABILITY
& PREFERENCES

How many weeks per year would
you like to work with Medlinx consultants, Inc.?

When can you start?

Part time Full time Per diem

What kind af work setting(s)
do you prefer?260

What shifts can
you work?

How many shifts per week can you work?

Clinical area of expertise:

What age groups can you work with, if applicable?

What location(s) would you prefer?

Where did you hear about Medlinx consultants, Inc.?

ACTIONS/
SANCTIONS
If your answer is "YES" to any of these questions, please provide full details on a separate sheet.

Have any of the following been, or are irony currently in the process of being, investigated, denied, revoked, suspended, reduced, limited, placed on probation, terminated, or placed under other disciplinary action? If yes, please provide a full explanation on a separate sheet.

a	Professional license in any state	Yes	No
b	Membership and/or employment	Yes	No
c	Clinical privileges/other rights	Yes	No
d	Rights on any hospital staff	Yes	No
e	Other institutional affiliation or status	Yes	No
f	Academic appointment	Yes	No

g	Training program	Yes	No
h	Professional society membership	Yes	No
i	Professional position	Yes	No
j	Other type of professional sanction	Yes	No
k	Participa.tion in any private, state, or federal health insurance program (e.g., Medicare, Medicaid)	Yes	No

Have you ever been employed where your employment was terminated by the employer?	Yes	No
Have you ever been convicted of, or pled guilty or no contest to, a criminal felony or misdemeanor, or are you currently under indictment for any alleged criminal activities?	Yes	No
Are you currently engaged in any illegal drug activity?	Yes	No
Have you ever been the object of an administrative, civil, or criminal complaint or investigation regarding sexual misconduct'?	Yes	No

HEALTH
STATUS
Please attach copies of TB Skin Test. Hepatitis B and Rubella Titers.

Are you able to perform competently the job-related functions of your specialty?		Yes		No
Are you able to travel and competently and promptly assume responsibilities in unfamiliar facilities?		Yes		No

TB Skin Test Results

Date Last Done

Chest X-Ray (tf unable to take Date last done TB Skin Test)

Date Last Done

Hepatitis BVaccination Dates:

Date of most recent Titer:

Results:

Rubella/ MMR Status:

Vaccination Date:

Date of most recent Titer:

Results:

Chickenpox status

Date of Illness:

Vaccination Date:

Date of most recent Titer:

Results:

EDUCATION/
TRAINING

School Name or Institution

Degree/ Certificate

Honors

City

State

Telephone

Dates attended

Date of graduation

School Name or Institution

Degree/ Certificate

Honors

City

State

Telephone

Dates attended

Date of graduation

BLS expires:

ACLS expires:

NRP expires:

PALS expires:

Other expires:

List of other Courses/ Certificates

WORK
EXPERIENCE
List in reverse chronological order, beginning with the most current, ALL employment affiliations since completion of education. (Attach a separate sheet, if' additional space is needed.)

Please explain any gaps in your work history on a separate sheet.

Name of Hospital / Company

Name & Title of immediate Supervisor

Address

Position held/
Job Description:

Dates
(mm/yy - mm/yy)

Starting Salary

Ending Salary

Name of Hospital / Company

Name & Title of immediate Supervisor

Address

Position held/
Job Description:

Dates
(mm/yy - mm/yy)

Starting Salary

Ending Salary

Name of Hospital / Company

Name & Title of immediate Supervisor

Address

Position held/
Job Description:

Dates
(mm/yy - mm/yy)

Starting Salary

Ending Salary

Name of Hospital / Company

Name & Title of immediate Supervisor

Address

Position held/
Job Description:

Dates
(mm/yy - mm/yy)

Starting Salary

Ending Salary

Name of Hospital / Company

Name & Title of immediate Supervisor

Address

Position held/
Job Description:

Dates
(mm/yy - mm/yy)

Starting Salary

Ending Salary

Name of Hospital / Company

Name & Title of immediate Supervisor

Address

Position held/
Job Description:

Dates
(mm/yy - mm/yy)

Starting Salary

Ending Salary

MILITARY
SERVICE

Branch

Dates of service (mm/yy-mm/yy)

Discharge status: Honorable Dishonorable
Other (Please specify)

PROFESSIONAL
REFERENCES
Please list 4 professional references with whom you have had clinical contact within the last 2 years. (At least 2 of these should be within your specialty) They should able to assess your professional skills and capabilities.

Name	Hospital / Institution	Phone

Have malpractice claims, lawsuits, settlements, or judgments been made
against you in the past? Yes (if yes, how many ) No
Are any pending? Yes No
Has your malpractice insurance coverage ever been denied, limited, or canceled? Yes No
Has a professional liability insurance carrier ever excluded any specific procedures
from your insurance coverage? Yes No
lf you answered "Yes" to any of the above, please provide details on a separate sheet.

Do you have your own professional liability insurance coverage? Yes No If yes. Please list name of carrier and amounts of coverage:

I am a Respiratory Therapist and I am interested in
Contract Opportunities.

I am an Allied Medical Professional (Techs/Clerical) and am interested in
Per Diem or Contract opportunities

I am an Allied Medical Professional (Techs/Clerical) and am interested in
Travel opportunities

I am a Physician and am interested in
Locum Tenens opportunities

I am a Physician and am interested in
Temp to Perm opportunities

I am a Certified Registered Nurse Anesthetist and am interested in
Locum Tenens or Temp to Perm opportunities

Other (if other please describe)

What is your life support provider status?
Basic Advanced Neo-Natal Pediatrics

Please indicate any other training or certification in your specialty:

What shifts are you willing to work? AM PM

Will you consider a long-term contract? Yes No

When are you available to start?

Tell Us What Staffing Opportunity You are Looking For:

I am an RN, LPN/LVN, CNA, ST or CST

and am interested in Travel opportunities

I hereby affirm that the information I have provided on this application and attachments is true and correct and that it can be relied upon by Medlinx consultants, Inc. ("Medlinx consultants, Inc.") for evaluating my potential as a health care provider.

I hereby authorize Medlinx consultants, Inc., its affiliates and successors, to obtain any information that may be relevant to an evaluation of my professional qualifications, including information pertaining to disciplinary actions, criminal background and history, or other confidential or privileged information, and other credentials.

I authorize Medlinx consultants, Inc. to disclose to current, prior, or potential employers making a reasonable inquiry, information relating to my qualifications, ability, and character.

Only to the extent requested and required by the practices, facilities, groups and hospitals staffed by Medlinx consultants, Inc.where I will be providing clinical services, I agree to provide and authorize the release of the same by Medlinx consultants, Inc.to Medlinx consultants, Inc. clients, the following: a) vaccination records; b) reasonable documentation evidencing that I am in good health and kee of communicable diseases; c) the result of and/or a copy of my criminal background check, if any; and d) the result of and/or a copy of my drug screen, if any.

I hereby release Medlinx consultants, Inc., it's of lancers, employees, agents and third parties that provide or receive information regarding my credentials, including, but not limited to. all credentialing information sources, individuals or companies who provide references. Companies or agencies that perform criminal background checks, and companies that perform drug screens from any claims, causes of action, damages and expenses. Including reasonable attorney's fees arising from relating to the collection, verification, Gild dissemination of my credentialing and other information.

I agree to hold Medlinx consultants, Inc. harmless from and against any and all claims, causes of action, damages, judgments and expenses, including reasonable attorney's fees, arising from or related to the accuracy at the information provided by mc, I understand that this does not contemplate a duty to hold Comp Henlth harmless from claims, causes of action and damages which may arise as a result of information provided about me from sources other than myself.
This is a continuing authorization and shall be effective from the date of signature below until such time as I have specifically revoked the same in writing.
If may material changes occur affecting my professional status, it is my obligation to notify Medlinx consultants, Inc. or the appropriate affiliate or successor as soon as possible. I understand tint the decision to employ me or refer me to practice opportunities is solely at the discretion of Medlinx consultants, Inc..
I unders1and that any information received from references by Medlinx consultants, Inc. is confidential and may not be released to me without the consent of the reference. I understand, agree and acknowledge that references are not part of my personnel file.

A copy or facsimile of this document shall have the same effect as the original.

This document shall be interpreted according to the laws of the state of Utah.

Name	Signature	Date