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All fields in RED are required to submit form.

Name

Phone

Address

City

State

Zip

Email

Position Applying For

Date Available

Available to work (check all that apply)

Full-Time Part-Time Temporary

Wage Desired

Are you a citizen of the US?

Yes No

Are you currently on lay-off status and subject to recall?

Yes No

May we contact your present employer?

Yes No

Are you willing to undergo a background check?

Yes No

Have you ever been convicted of a felony?

Yes No

What was the felony charge for? Please explain below:

Are you on parole?

Yes No

This job requires a home office and locked file cabinet. Do you have these items at your home?

Yes No

Please provide information regarding your computer, operating system and software you use for transcription.

Have you ever worked from home with little or no supervision with the expectation of meeting strict deadlines?

Yes No

Do you have a clear understanding of HIPAA compliance and laws?

Yes No

What experience do you have in medical transcription specialties? Legal transcription, focus groups, interviews, general transcription, etc. Please be specific. Enter answer below:

Education

High School (name and location)

Diploma or Equivalency?

Yes No

For Undergraduate/Graduate/Technical Education

Name & Location of School

Years Completed

Major Subject

Graduated (Y/N)

Graduate Date

Degree & GPA

Personal References

Name of reference 1

Phone

Relationship

Name of reference 2

Phone

Relationship

Name of reference 3

Phone

Relationship

Describe any specialized training, apprenticeship, certification and/or skill?

Employment

Name & Address of Employer (1)

From:

To:

Supervisor

Position Title

Name & Address of Employer (2)

From:

To:

Supervisor

Position Title

Name & Address of Employer (3)

From:

To:

Supervisor

Position Title

Experience in this Field?

Please upload your resume here