First Name *
Last Name *
Address *
Address
City *
State *
Zip Code *
Email *
Home Phone
Business Phone E.G. 888-555-5555 X 555 (Include extension if applicable)
Mobile Phone
Alternate Phone
Fax Number
User Name *
Password *
Verify Password *
   
Referred By
Current Title  If Student, please enter your graduation year  
Practice Settings
Select all that apply
  Years of experience at setting
  Retail
  Clinic
  Hospital
  Mail-Order
  Home Infusion
  Long Term Care
  Institutional
  Pharmaceutical
  Nuclear
     
Department Inpatient
  Outpatient
  Satellite
  Consultant
   
Computer experience:
Please hold down <CTRL> to select multiple
Other Computer Experience
Specialty Select all that apply
Acute Care Aids/HIV
Ambulatory Care Cancer Care
Cardiology Diabetes Educator
Geriatric Infectious Disease
Intensive Care Managed Care
Med/Surg Neonatal
Nutrition Obstetrics
Oncology Operating Room
Other - see notes Pediatric
Pharmacokinetics Rehabilitation
State
Please hold down <CTRL> to select multiple
Maximum hours per week
   
Meds Prepared IV      Oral      Both
IV's Prepared AB
TPN
Chemo
Hyperal
IV to PO Conversion Yes     No
Renal Dosing Yes     No
Cart Fill Yes     No
Willing to Travel Yes     No
   

Please select the dates that you are available to work.

August 2018
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Please select the shifts that that you will be available to work.
Dayshift (1st shift)
Evening (2nd shift)
Weekend Day (1st shift)
Weekend Evening (2nd shift)
Nightshift (3rd shift)
Weekend Nightshift (3rd shift)

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