Days/ Hours Available to Work:
No Preference	Monday	Tuesday	Wednesday
Thursday	Friday	Saturday	Sunday

Have you ever worked for SoftScript?	Yes	No
If yes, what year?
I can transcribe 135 lines:	Yes	No
I can maintain a minimal or 98% accuracy:	Yes	No

Employment Desired?
FULL-TIME-ONLY	PART-TIME ONLY

EDUCATION AND OTHER INFORMATION
TYPE OF SCHOOL	NAME OF SCHOOL	LOCATION (Complete mailing address)	YRS. COMPLETED	MAJOR & DEGREE
High School

College

Bus. or Trade School

Professional School

Please list two emergency contacts
Name:	Name:

Address:	Address:

Telephone:	Telephone:

Have you ever been convicted of a crime?	Yes	No
If yes, please explain:

Please list two professional references other than a relative
Name:	Name:

Position:	Position:

Address:	Address:

Telephone:	Telephone:


An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the space below to add any additional information necessary to describe your full qualifications for the specific position for which you are applying.



MILITARY
Have you ever been in the Armed Forces?	Yes	No
Are you now a member of the National Guard?	Yes	No
Specialty:
Date Entered:
Discharge Date:

Work Experience
Job One
Name of Employer:	Name of last Supervisor:	Employment Dates	Salary
		From:	Start:
Complete Address:	Phone Number:	To:	Final:

Job Title:
Reason for leaving? (be specific) :
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.
Number of lines transcribed per hour/day:	Hour-
Last Audit Score:	Day-
Job Two
Name of Employer:	Name of last Supervisor:	Employment Dates	Salary
		From:	Start:
Complete Address:	Phone Number:	To:	Final:

Job Title:
Reason for leaving? (be specific) :
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.
Number of lines transcribed per hour/day:	Hour-
Last Audit Score:	Day-
Job Three
Name of Employer:	Name of last Supervisor:	Employment Dates	Salary
		From:	Start:
Complete Address:	Phone Number:	To:	Final:

Job Title:
Reason for leaving? (be specific) :
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.
Number of lines transcribed per hour/day:	Hour-
Last Audit Score:	Day-

Rate your computer skills on a scale of 1-5. 5 being the highest	1	3
List the software programs you are proficient with:
May we contact your present employer?	Yes	No
Did you complete this application yourself?	Yes	No
If not who did?

Your Experience Profile
Please list your years of experience in each area:

	Multi Specialty Clinics		Acute Care
	Radiology		Pathology

Use this rating system for the following questions
1. No Experience
2. Need Improvement
3. Average
4. Very Good
5. Excellent

Please rate your experience level	1	2	3	4	5
H&P
Clinic/Progress Notes
Consult
OP
Cardiac Cath
DS
ER
Radiology
Pathology
Cardiology (EKG, ECHO, Holter)
Neurodiagnostic Studies (EMG, EEG, nerve conduction studies)

Are you proficient with accents?	1	2	3	4	5
Asian
Middle Eastern
Hispanic
Indian
Fast Dictators

What is your proficiency for each specialty?	1	2	3	4	5
GI/GU
Otolaryngology
General Surgery
Cardiology
Ophthalmology
Neurology
Pulmonology
Dermatology
Neurosurgery
Family Medicine
Allergy/Immunology
Plastic Surgery
Internal Medicine
Infectious Disease
Oncology
Orthopedics
Hematology
OB/GYN
Podiatry
Radiology/Oncology
Psychiatry
Pain Mgmt/Anesth
Pediatrics

How many hours can you work weekly?	Can you work nights?

Salary Desired?	How did you learn about this position?

	What size facilities have you worked in?
	What is your average daily production?

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