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| Company internal Job ID Number for this position |
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| CRNA's Name (Preferred Name in parenthesis if desired) |
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| Contact Name |
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| Contact Email |
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| Contact Street Address 1 |
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| Contact City |
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| Contact State |
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| Contact Zip Code |
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| Contact Country |
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| Contact Voice Phone |
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| Contact Fax |
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| Contact Web Site |
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| Preferred Contact Method |
| Brief Description of Candidate |
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| States where clinician wants to work |
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| Check any Position Durations you would consider: |
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| Date Available |
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| If Locum Tenens, to what end date can CRNA work? |
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| Does CRNA want a Chief CRNA position? |
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| Does CRNA want a job that leads to partnership? |
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| How often the CRNA wants to do the following: |
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| Does the CRNA want to be Medically Directed by an Anesthesiologist? |
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| What is the CRNA's preference regarding CRNAs in a job situation doing Operative Cases that are not Medically Directed by an Anesthesiologist? |
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| Does the CRNA want a job where there is an Approved Physician Anesthesia residency program? |
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| Does the CRNA want a job where there is Anesthesia training for Physician house staff? |
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| Does the CRNA want a job where there is a CRNA training program? |
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| Does the CRNA want a job where there is an Anesthesiologist's Assistant training program? |
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| What practice setting(s) does the CRNA have experience? |
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| Employment Status Desired: Employee (IRS form W-2) or Independent Contractor (IRS form 1099). |
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| Does the CRNA want a Salary income from anesthesia group? |
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| Does the CRNA want a Percentage income from anesthesia group? |
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| Does the CRNA want an Income from Fee-for-service individual practice? |
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| Does the CRNA want a Salary from Hospital as an employee? |
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| Does the CRNA want Other income as a Hospital employee? |
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| How often Does the CRNA want to be on call? |
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| Does the CRNA want to have the Day off after call? |
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| States where CRNA is licensed |
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| CRNA's Degree |
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| CRNA's Nurse School |
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| CRNA's Anesthesia School |
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| Is CRNA Certified by the NBCRNA? NBCRNA = National Board on Certification and Recertification of Nurse Anesthetists |
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| Year of Primary Certification |
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| Comments about CRNA's NBCRNA Certification NBCRNA = National Board on Certification and Recertification of Nurse Anesthetists |
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| Has CRNA completed Subspecialty Extra training |
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| Does CRNA have Subspecialty Expertise but has not completed extra training? |
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| If CRNA has Subspecialty expertise or has completed extra training, which one(s)? |
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| Check which Life Support cards you currently have: |
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| Is CRNA a New Graduate? |
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| Current Employer Name |
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| Current Employer Address/City/State/Zip |
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| CRNA's reason for seeking a job change? |
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| CRNA's Interests |
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| Name of a reference person |
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| Reference's email |
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| Reference's phone |
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| Indicate any other comments you may have |
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