General Job Application for I & R

Full Name

First NameLast Name

Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Email Address

Phone Number

Area CodePhone Number

What are your preferred shifts and scheduling parameters for W-2 or relief coverage?

Please specify your preferred role type (e.g., full-time, part-time, relief, or locum)

Please specify your geographic flexibility and the maximum distance you are willing to travel for work:

Desired annual base salary for direct-hire opportunities (if applicable):

Please provide your relief shift/hourly rate (if applicable):

Please list all states where you hold an active veterinary license in good standing:

What tax classification do you prefer for contract work? (W-2 Only / 1099-Independent Contractor Only / Open to Both

Date You can Start Working:

MonthDayYear

Please let us know exactly what you are seeking in your next career role i.e. compensation, title, etc.:

Specialty/Interest Areas

Have you ever had a state veterinary license, DEA registration, or controlled substance license suspended, revoked, or placed on probation, or are you currently under investigation by any state board?

Do you hold a valid federal DEA registration and active professional liability insurance (PLIT)?

Education

Please specify degrees, certifications, and educational accomplishments.

Work History

Most Current Company Name

Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

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