If you would like Celebrity Medical to represent you, fully complete and submit the form below.  Please be aware that we prefer to call you during the day and will be extremely discrete when doing so.  However if you do not wish to be called at work, do not forget to fill out the best time to reach you.

If you prefer to e-mail us a resume, make sure it is either a plain text file or a Microsoft word document.  Be sure to include a day phone number and and evening phone number as well as the best times to reach you.

To return to the Celebrity Medical home page close this browser after submitting the form.

Please provide the following information:

Full Name

Street Address

Address (cont.)

City, State, Zip

Work Phone

Best Time to Reach You at Work

Home Phone

Best Time to Reach You at Home

FAX

E-mail

Date of Birth	-- mm/dd/yy
Social Security Number
U.S. Citizen	Yes No
Green Card	Yes No

How long have you lived in this area?	Years
If you are planning to move to the Washington Metro area, When will you be arriving?	-- mm/dd/yy

Date available for work

-- mm/dd/yy

Employment Record:

Please List three your last 3 permanent full- or part-time positions you have held beginning with the most current position first.

Name of Employer
Employer's Specialty
City, State, Zip
Your Title
Current of Final Salary  Received	per year
Software used	CBSI MED MGR   Other
Responsibilities Included:
Date  Started	-- mm/dd/yy
Date Left:	-- mm/dd/yy
Reason for leaving

Name of Employer
Employer's Specialty
City, State, Zip
Your Title
Current of Final Salary  Received	per year
Software used	CBSI MED MGR   Other
Responsibilities Included:
Date  Started	-- mm/dd/yy
Date Left:	-- mm/dd/yy
Reason for leaving

Name of Employer
Employer's Specialty
City, State, Zip
Your Title
Current of Final Salary  Received	per year
Software used	CBSI MED MGR   Other
Responsibilities Included:
Date  Started	-- mm/dd/yy
Date Left:	-- mm/dd/yy
Reason for leaving

Education Record:

High School
Dates Attended	mm/yy-mm/yy

College or University
Dates Attended	mm/yy-mm/yy
Major
Diploma or Degree	mm/yy

Vocational School
Dates Attended	mm/yy-mm/yy
Major
Diploma or Degree	mm/yy

References: Give three (3) personal references:

Name

Phone

Name

Phone

Name

Phone

Have you applied to other firms in the last three (3) months?

Yes No

If so, please state:

Since our main goal is to help assist you in finding a rewarding position within the medical field, please give us a brief description of your ideal work situation!  (salary, location, growth opportunity, work environment, etc.)

All of the above information must be true.  Any false information or deliberate omission of pertinent information regarding character or experience may be grounds for dismissal.

To return to the Celebrity Medical home page close this browser after submitting the form.