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After filling the form, you may send it to AHA by clicking on submit button. You may print a copy also.

Personal Information

Full Name
 Profession
Present Mailing Address
City
 State
 Zip
 Country
Telephone
 Alternate Telephone
 Permanent Telephone
Email
Date of Birth
 Place of Birth
 Citizenship
Marital Status
 Dependants
 Name of the Spouse
Permanent Address
Emergency Contact: Name
 Relationship
 Telephone
Emergency Contact:Address

Education

  Name & Location of School Years Degree/Diploma Major/Subjects
1.
2.
3.
4.
General - Special Study/Research/Special Training/Skills

International Applicable Requirements

Exam Date Score/Pass
CGFNS
NCLEX-RN
VISA SCREEN
TOEFL
TSE
TWE
TOICE
IELTS

Employment History

1. From
 To
Position
Job Responsibilities
Name, Address and Telephone of Employer
Supervisor
Reason for Leaving

2. From
 To
Position
Job Responsibilities
Name, Address and Telephone of Employer
Supervisor
Reason for Leaving
3. From
 To
Position
Job Responsibilities
Name, Address and Telephone of Employer
Supervisor
Reason for Leaving
4. From
 To
Position
Job Responsibilities
Name, Address and Telephone of Employer
Supervisor
Reason for Leaving

Experience

Area Mo/Yrs Area Mo/Yrs
Surgical Floor Gen Medicine
ICU/CCU PreNatal/NeoNa
Oncology OR
Labor/Delivery Psychiatry
Pediatrics Chemistry
Physics Math

Are you physically & financially able to travel to America? Yes No
Can you stay away from home and relatives on assignment, for an extended period? Yes No
Is there any physical disability that prevent you from performing your area of skills? Yes No
Have you ever had any mental disorders? Yes No
Are you in good physical health? Yes No
Are you pregnant? Yes No
Are you on any medication? Yes No
Have you ever had any disciplinary actions taken against you? Yes No
Are you currently under any investigation? Yes No
Have you ever applied for a US visa? Yes No
Have you ever been denied of a US visa? Yes No
Do you have any relatives in America? Yes No
Would your family, if married, want to travel with you to America? Yes No
Have you ever been to America? Yes No

Parents - Guardian

Fathers Name
 Mothers Name
Mailing Address
Permanent Address
Telephone
 Telephone/Fax
 Email

References - Personal/Professional

1.Name
 Relationship
Mailing Address
Telephone
 Telephone/Fax
 Email

2.Name
 Relationship
Mailing Address
Telephone
 Telephone/Fax
 Email
3.Name
 Relationship
Mailing Address
Telephone
 Telephone/Fax
 Email

Additional Info

Please Provide any additional information that might help your application:

    


Contact Information.

Advanced Health Alliance, Inc.
1001 Medical Park Drive, SE. Suite 111
Grand Rapids, Michigan 49546-3677,
USA
Telephone: 616-977-3200
Fax: 616-956-0059
email: info@advancedhealthalliance.com

Copyright © 2007 Advanced Health Alliance, Inc.
Last Revised: