Ready to join the team? Employment application. Step 1 of 14 7% INTRODUCTION You must use Desktop Chrome, Firefox or Safari to complete this form. Mobile web browsers may NOT work properly. Welcome to Epic Cardiovascular Staffing online employment application service. This service is intended to standardize and streamline the employment process for both applicants and employers. If you are an Epic Cardiovascular Staffing member and are applying for a position listed on our website, you may complete this online application, and the application results will be sent directly to the employer specified in the application. Privacy Concerns: Some sensitive personal information is collected during the application process. This information is stored securely on our servers and will only be shared with the employer who submitted the position. The results of your application will not be shared with any 3rd parties or recruiters without your consent. Instructions: Complete the online application making sure your fill out each item carefully. Some items are required and other items are optional. It is recommend that you complete the optional items. If you are not able to complete the employment application in one sitting, you may return and update your application three within (3) days. If you have questions about the online application process, please contact our Human Resources Department. Confirmation*I have read and understand the Employment Application terms and instructions. Yes No Name* First Middle Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Enter Email Confirm Email Mobile Phone*Home PhoneEmergency Contact* First Name Last Name Relationship Emergency Contact Number* APPLICANT DETAILSAuthorization to work in the US*Are you legally authorized to work in the US ? Yes No POSITION INFORMATIONTitle of Position*Please enter the of tile of the positon(s) you are applying for. Clinical Perfusionist Chief Perfusionist Traveling Perfusionist Autotransfusionist ECLS Specialist Other Location*Please enter the name and/or location of the position you are applying for (hospital, city and state). Salary Requirement*Please enter your minimum annual salary requirement in U.S. Dollars. Please consider this carefully and input a realistic value.Please enter a number from 5000 to 500000.Start Date*Please enter the date you would be available to begin work. MM slash DD slash YYYY Introduction LetterThis is not required, but it's a nice touch to add a personal letter to go along with your application. Drop files here or Select files Accepted file types: pdf, jpg, png, bmp, doc, docx, Max. file size: 512 MB. Resume Upload* Drop files here or Select files Accepted file types: pdf, jpg, png, bmp, doc, docx, Max. file size: 512 MB. EDUCATION INFORMATIONName of High School Name of College or Undergraduate School Name of Graduate School or Perfusion Program Perfusion School Graduation Date MM slash DD slash YYYY Degrees, Licenses and Certifications*Please select any degrees and/or certifications that you have obtained. CCP RN BSN CNOR CPMBT CCT MS RRT BS BA MD PhD Other Upload DocumentsPlease upload a copy of any degrees or certification that you have obtained. Drop files here or Select files Accepted file types: pdf, jpg, png, bmp, doc, docx, Max. file size: 512 MB. EMPLOYER #1Employer #1*This should be your most recent position. Date Employment Began* MM slash DD slash YYYY Date Employment Ended* MM slash DD slash YYYY Job Title* Employer Email Employer PhoneEmployer Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Reason for Leaving* EMPLOYER #2Employer #2 Email Date Employment Began MM slash DD slash YYYY Date Employment Ended MM slash DD slash YYYY Reason for Leaving EMPLOYER #3Employer #3 Email Date Employment Began MM slash DD slash YYYY Date Employment Ended MM slash DD slash YYYY Reason for Leaving Employment Agreement*Have you been employed under a written employment agreement within the last five (5) years? Yes No HiddenRestrictive CovenantDoes your employment agreement contain a covenant that in any manner restricts your employment during or after the termination of said written employment agreement?* Yes No HiddenUpload Employment AgreementPlease upload a copy of your current employment agreement. Drop files here or Select files Max. file size: 512 MB. FIRST REFERENCEReference Name* First Last PhoneReference Email* Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Upload Reference Letters Drop files here or Select files Accepted file types: pdf, jpg, png, bmp, doc, docx, Max. file size: 512 MB. 2ND REFERENCEReference Name* First Last PhoneReference Email* Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code 3RD REFERENCEReference Name* First Last PhoneReference Email* Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code EEOC Questionnaire The Equal Employment Opportunity Commission (EEOC) requires all private employers with 100 or more employees as well as federal contractors and first-tier subcontractors with 50 or more employees AND contracts of at least $50,000 complete an EEO-1 report each year. Covered employers must invite employees to self-identify gender and race for this report. Completion of this form is voluntary and will not affect your opportunity or the terms and conditions of your employment. This form will be used for EEO-1 reporting purposes only and will be kept separate from all other personnel records only accessed by the Human Resources department. If you choose not to self-identify your race/ethnicity at this time, the federal government requires Perfusion.com to determine this information by visual survey and/or other available information.Name:* First Last Job Title:* Date Completed:* MM slash DD slash YYYY Gender:* Male Female Prefer not to answer Race/Ethnicity:*(Please check one of the descriptions below corresponding to the ethnic group with which you identify.) Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. White (Not Hispanic or Latino): A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. Black or African American (Not Hispanic or Latino): A person having origins in any of the black racial groups of Africa. Native Hawaiian or Pacific Islander (Not Hispanic or Latino): A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands. Asian (Not Hispanic or Latino): A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. Native American or Alaska Native (Not Hispanic or Latino): A person having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment. Two or more races (Not Hispanic or Latino): All persons who identify with more than one of the above five races. Prefer not to answer Veteran Status* I am a Veteran I am Not a Veteran Prefer not to answer Disability Status* I have a disability I do not have a disability Prefer not to answer Additional CommentsPlease provide any additional detail that you feel is relevant in the comments box below.ConfidentialityWould you like your application to be treated as "Highly Confidential"? Yes No Signature*Please sign your employment application by typing in your full name. CAPTCHANameThis field is for validation purposes and should be left unchanged.