To apply for a job at VisionQwest, simply fill out the form below. Required fields are marked with an asterisk (*). Our Recruitment Manager will be in contact with you upon determining your eligibility for the desired position.

Thank you for considering VisionQwest.

I am applying for*:	Desired Position Accountant Nurse - RN Caregiver/Nanny Physical/Occupational Therapist Medical Assistant/Technologist Respiratory Therapist LVN/LPN CNA Call Center - Team Leader Call Center - Agent Medical Transcriber
I am applying from*:	Current Location USA Philippines India Other location  If other location, pls specify:
APPLICANT NAME*
First Name	Middle Name	Last Name
HOME ADDRESS*
House no., Street	City/Province, State, Zipcode	Country
CONTACT INFORMATION*
Day Phone no.	Evening Phone no.	Mobile Phone no.
E-mail Address	Birthday	Birthplace
EDUCATIONAL BACKGROUND*
Highschool Year Graduated	College Year Graduated	Other Year Graduated

WORK EXPERIENCE (Kindly list your last three jobs.)
JOB 1
Date Employed	From   To
Company Name
Business Address
City/Province		Country
Zipcode		Phone no.
Supervisor's Name		Phone no.
Fax No.		E-mail Address
Title/Position		Salary	Select Per Hour Per Month Per Year
Duties & Responsibilities
Reasons for Leaving
JOB 2
Date Employed	From   To
Company Name
Business Address
City/Province		Country
Zipcode		Phone no.
Supervisor's Name		Phone no.
Fax No.		E-mail Address
Title/Position		Salary	Select Per Hour Per Month Per Year
Duties & Responsibilities
Reasons for Leaving
JOB 3
Date Employed	From   To
Company Name
Business Address
City/Province		Country
Zipcode		Phone no.
Supervisor's Name		Phone no.
Fax No.		E-mail Address
Title/Position		Salary	Select Per Hour Per Month Per Year
Duties & Responsibilities
Reasons for Leaving

FOR ACCOUNTING CANDIDATES ONLY (Please check all those that apply.)
Quickbooks Rate your knowledge Basic Intermediate Advanced  SAP Rate your knowledge Basic Intermediate Advanced  Peach Tree Rate your knowledge Basic Intermediate Advanced  Microsoft Excel Rate your knowledge Basic Intermediate Advanced  Microsoft PowerPoint Rate your knowledge Basic Intermediate Advanced  Microsoft Access Rate your knowledge Basic Intermediate Advanced  Microsoft Word Rate your knowledge Basic Intermediate Advanced  Microsoft Outlook Rate your knowledge Basic Intermediate Advanced
List other related software systems you know and rate your expertise with each:

FOR NURSING CANDIDATES ONLY
Have You Passed the Nursing Board Exams? (NCLEX)	Yes   No Not Applicable	License Number
State/s Passed		Country/ies Passed
Have you passed the CGFNS? *Philippine Applicants only	Yes   No Not Applicable	Have you passed the TOEFL? *Philippine Applicants only	Yes   No Not Applicable

DISCIPLINARY ACTIONS

Have you ever been convicted of a felony or a misdemeanor? (A "yes" answer will not automatically disqualify you from consideration for placement. Factors such as when the offense was committed and the seriousness and nature of the offense will be considered.) Yes  No If YES, please explain.

I hereby certify that all the above information is true and correct and answered to the best of my knowledge and ability.

If you are not applying for a HEALTHCARE or MEDICAL profession, your application is complete. Please review your data and then click on the SUBMIT button at the bottom of this page. If you are a medical or a healthcare professional, CONTINUE ON.

FITNESS FOR POSITION - HEALTHCARE PROFESSIONALS ONLY
1. The essential function of a healthcare provider is to provide a standard of care that is acceptable within his/her specialty. Are you capable of performing this function with or without reasonable accommodation?	Yes  No
2. Are you authorized to work in the United States?	Yes  No
3. Are you currently abusing alcohol, using any illegal drugs, or failing to take legally prescribed drugs in the manner prescribed?	Yes  No
4. Have you abused alcohol, used illegal drugs, or failed to take legally prescribed drugs in the manner prescribed in the past?	Yes  No
PROFESSIONAL LIABILITY - LICENSED NURSES ONLY
1. Have any malpractice claims, suits, settlements or arbitration proceedings been made against you?	Yes  No
2. Are there any claims, suits or settlements pending against you or against any professional entity in which you are a member?	Yes  No
If you answered YES to any of these questions, please include a personal summary on each case to include: the year it occurred, status (i.e., pending, closed, etc.), settlement amount, details of the case, malpractice carrier and other relevant information. In addition to your summary of events, kindly include any or all additional documentation available from attorneys and/or malpractice carriers.
DISCIPLINARY DECLARATIONS- LICENSED NURSES ONLY

1. Have you ever been convicted of any violation of a state or federal law relating to controlled substances? (A "yes" answer will not automatically disqualify you from consideration for placement. Factors such as when the offense was committed and the seriousness and nature of the offense will be considered.)	Yes  No If YES, please explain.
2. Have you ever been denied or surrendered a state or federal controlled substances certificate?	Yes  No If YES, please explain.
3. Has your license to practice in your profession in any state been reprimanded, sanctioned, placed on probation, curtailed, or placed under conditions restricting your practice?	Yes  No If YES, please explain.
4. Have you ever been denied a certificate by, or the privilege of taking an examination before, any state board?	Yes  No If YES, please explain.
5. Have your staff/clinic privleges at any hospital, health care facility, or clinic been denied, revoked, suspended, curtailed, limited, or placed under conditions restricting your practice?	Yes  No If YES, please explain.
6. Have you ever been terminated from employment?	Yes  No If YES, please explain.
7. Have you ever been disciplined by any state board for a violation of the Medical Practice Act or unethical conduct?	Yes  No If YES, please explain.
8. Have you ever been denied provider participation in any state or federal Medicare or Medicaid programs?	Yes  No If YES, please explain.
9. Have you ever been terminated, sanctioned, penalized or had to repay money to any state or federal Medicare/Medicaid?	Yes  No If YES, please explain.
10. Have you ever been the subject of any investigative or disciplinary proceedings or reprimanded by a governmental or administrative agency?	Yes  No If YES, please explain.
11. Have you ever been convicted of a violation of any federal or state narcotic laws? (a "yes" answer will not automatically disqualify you from consideration for placement. Factors such as when the offense was committed and the seriousness and nature of the offense will be considered.)	Yes  No If YES, please explain.
12. Have you ever been disciplined by a hospital staff or training program?	Yes  No If YES, please explain.
13. Is there any other issue that should be disclosed that may have an adverse impact on your ability to deliver effective care?	Yes  No If YES, please explain.
I hereby certify that all the above information is true and correct and answered to the best of my knowledge and ability.