Step 1 of 6 16% Please complete our online application to apply to be an independent contractor with TotalWellness. Fields marked with an asterisk (*) are required. After submitting your application, TotalWellness will contact you via email (please watch your spam/junk folder). If you have questions during the application process contact TotalWellness at 888.434.4358 or RNS@totalwellnesshealth.com.Personal InformationName* Legal First Name Legal Middle Name Legal Last Name Preferred First Name (if different than legal name) Email* TotalWellness hires medical professionals as independent contractors to work on an as-needed basis. Most work opportunities are Monday-Friday during daytime hours (usually between 7am-4pm). With enough notice, would you be able to work during such hours?* Yes No If you are not interested in working on an as needed basis or if you are unable to work Monday - Friday during normal business hours we recommend that you do not complete the application process. Home Phone Number:Mobile Phone Number:Work Phone Number: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 Emergency Contact Name: First Last Emergency Contact Phone Number:Are you a nurse or an other medical professional?* Nurse Other Medical Professional Choose your profession(s), select all that apply:* Chiropractor Clerical Staff CNA EMT/Paramedic Foreign Doctor Health & Wellness Coach Health Educator Instructor (Any Medical Profession) Interpreter LPN LVN MA Massage Therapist Med Tech MD/DO Personal Trainer Pharmacist Phlebotomist Physician's Assistant Respiratory Therapist RN Student Ultrasound Tech Other (please specify) Other/Specify Profession*Are you 18 years old or older?* Yes No Upload your resume:Max. file size: 50 MB.Upload your government issued photo ID:Max. file size: 50 MB.Be sure the image of your photo ID is readable before uploading. Employment History:Please enter your employment history. You may enter up to 5 employment histories.Employment History - 1* Company Name Job Title City State Employment Timeframe Job description, responsibilities & duties:*Would you like to add a second employment history? Yes No Employment History - 2* Company Name Job Title City State Employment Timeframe Job description, responsibilities & duties:*Would you like to add a third employment history? Yes No Employment History - 3* Company Name Job Title City State Employment Timeframe Job description, responsibilities & duties:*Would you like to add a fourth employment history? Yes No Employment History - 4* Company Name Job Title City State Employment Timeframe Job description, responsibilities & duties:*Would you like to add a fifth employment history? Yes No Employment History - 5* Company Name Job Title City State Employment Timeframe Job description, responsibilities & duties:* EducationPlease enter your education history. You may enter up to 5 education histories.Education History - 1* Degree/Certificate Achieved School Name Education Timeframe Would you like to add a second education history?* Yes No Education History - 2* Degree/Certificate Achieved School Name Education Timeframe Would you like to add a third education history?* Yes No Education History - 3* Degree/Certificate Achieved School Name Education Timeframe Would you like to add a fourth education history?* Yes No Education History - 4* Degree/Certificate Achieved School Name Education Timeframe Would you like to add a fifth education history?* Yes No Education History - 5* Degree/Certificate Achieved School Name Education Timeframe Highest Education Level*Some High SchoolHigh School Diploma/GEDSome CollegeTrade or Technical School DiplomaAssociate's DegreeBachelor's DegreeMaster's DegreePhDOther Licenses/CertificationsPlease enter your current license(s) and/or certification(s). You may enter up to 5 licenses/certifications.License/Certification*Certified Health and Wellness CoachCertified Nursing Assistant (CNA)ChiropractorCPR/BLSDietitian/NutritionistDoctor - DODoctor - ForeignDoctor - MDEMT/ParamedicMassage TherapistMedical Assistant (MA, CMA)Medical TechnicianNurse - LPNNurse - LVNNurse - RNNurse PractitionerPersonal TrainerPharmacistPharmacy Technician/AssistantPhlebotomistPhysician Assistant (PA)Respiratory TherapistUltrasound TechnicianI do not have any of these types of licenses/certificationsLicense/Certification Information Not ApplicableAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Issue date Expiration date Number Issuing body Upload license or certificate:Max. file size: 50 MB.Would you like to add a second license or certificate? Yes No License/Certification - 2*Certified Health and Wellness CoachCertified Nursing Assistant (CNA)ChiropractorCPR/BLSDietitian/NutritionistDoctor - DODoctor - ForeignDoctor - MDEMT/ParamedicMassage TherapistMedical Assistant (MA, CMA)Medical TechnicianNurse - LPNNurse - LVNNurse - RNNurse PractitionerPersonal TrainerPharmacistPharmacy Technician/AssistantPhlebotomistPhysician Assistant (PA)Respiratory TherapistUltrasound TechnicianLicense/Certification Information - 2 Not ApplicableAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Issue date Expiration date Number Issuing body Upload license or certificate:Max. file size: 50 MB.Would you like to add a third license or certificate? Yes No License/Certification - 3*Certified Health and Wellness CoachCertified Nursing Assistant (CNA)ChiropractorCPR/BLSDietitian/NutritionistDoctor - DODoctor - ForeignDoctor - MDEMT/ParamedicMassage TherapistMedical Assistant (MA, CMA)Medical TechnicianNurse - LPNNurse - LVNNurse - RNNurse PractitionerPersonal TrainerPharmacistPharmacy Technician/AssistantPhlebotomistPhysician Assistant (PA)Respiratory TherapistUltrasound TechnicianLicense/Certification Information - 3 Not ApplicableAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Issue date Expiration date Number Issuing body Upload license or certificate:Max. file size: 50 MB.Would you like to add a fourth license or certificate? Yes No License/Certification - 4*Certified Health and Wellness CoachCertified Nursing Assistant (CNA)ChiropractorCPR/BLSDietitian/NutritionistDoctor - DODoctor - ForeignDoctor - MDEMT/ParamedicMassage TherapistMedical Assistant (MA, CMA)Medical TechnicianNurse - LPNNurse - LVNNurse - RNNurse PractitionerPersonal TrainerPharmacistPharmacy Technician/AssistantPhlebotomistPhysician Assistant (PA)Respiratory TherapistUltrasound TechnicianLicense/Certification Information - 4 Not ApplicableAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Issue date Expiration date Number Issuing body Upload license or certificate:Max. file size: 50 MB.Would you like to add a fifth license or certificate? Yes No License/Certification - 5*Certified Health and Wellness CoachCertified Nursing Assistant (CNA)ChiropractorCPR/BLSDietitian/NutritionistDoctor - DODoctor - ForeignDoctor - MDEMT/ParamedicMassage TherapistMedical Assistant (MA, CMA)Medical TechnicianNurse - LPNNurse - LVNNurse - RNNurse PractitionerPersonal TrainerPharmacistPharmacy Technician/AssistantPhlebotomistPhysician Assistant (PA)Respiratory TherapistUltrasound TechnicianLicense/Certification Information - 5 Not ApplicableAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Issue date Expiration date Number Issuing body Upload license or certificate:Max. file size: 50 MB.Do you hold a current CPR certification? Yes No CPR Certification Information Not ApplicableAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Issue date Expiration date Number Issuing body Upload CPR certificate:Max. file size: 50 MB. QuestionsPlease answer the questions below.How much clinical/medical experience have you had?*0-1 years1-3 years3-5 years5 or more yearsTell us about your past clinical/medical experience.*Please explain any gaps in your medical/clinical experience that are greater than 2 years.Are you proficient at venipuncture blood draws? (Not a requirement to work with us)* Yes No Do you speak Spanish fluently? (Not a requirement to work with us)* Yes No Prior to an event, you may be shipped bulky, heavy equipment or you may be asked to help set-up/clean-up an event. This equipment could weigh up to 30 pounds. Are you able to move and lift items that weigh up to 30 pounds?* Yes No Has a professional license of yours ever been suspended, revoked, placed on probation, been a subject of any disciplinary proceedings or have you ever voluntarily surrendered your license?* Yes No Please Explain:*Are you willing and able to pass a criminal background and drug test?* Yes No Please Explain:*How did you hear about TotalWellness?*BrightCareerBuilderCraigslistFacebookGeeboGlassdoorGoogleHotJobsIndeed.comLinkedInMonsterOther (please specify)Referral (please specify)SimplyHiredTheLaddersTop USA JobsTotalWellness WebsiteZipRecruiterOther/Specify Source:Referred by:I certify that all information in this application is true and correct as of the date listed below:eSignature:*eSignature Date:* MM slash DD slash YYYY