MEDICAL APPLICANT PROFILE FORM

We need you to send your CV/resume along with application form for consideration. This enable us to assist you better with position placement. Your CV and application form will also be used to present you as a candidate for assignments, in which you express your interest. That's why is very important that your information must be comprehensive, up-to-date and reflective of your full range of skills. In the STEP ONE you must attach your current CV/resume and advisably one of your pictures of size 3 x 4 cm.

STEP ONE:
 Attachments: 
Photo (3 x 4 cm)
(must be not larger than 300KB. Only these extensions are allowed: jpg,jpe,jpeg,gif,bmp,png):
CV/RESUME (must be not larger than 300KB. Only these extensions are allowed: doc,pdf,txt)

or send as attachment to:

 

Please note!
This is important that after you have attached your CV/resume, you must go to STEP TWO to fill in the application form below:

STEP TWO:

 Personal Information: 
First name:
 Last name:
Date of birth:
- - 		Gender: Male Female
Nationality:
 Religion:
Marital status: Number of children:
 Address: 
Country:
 Zip Code:
 City:
Address:
Home Phone (with country and area code):
 Work Phone (with country and area code):
Mobile Phone (with country and area code):
 Fax (with country and area code):
E-mail (check carefully):
 Basic Information: 
Medical School of Graduation:
 Year of Graduation:
Speciality:
 Experience (Years):
Post Graduate or Training:
School name:   Year Graduated:   Degree:
School name:   Year Graduated:   Degree:
School name:   Year Graduated:   Degree:
School name:   Year Graduated:   Degree:
School name:   Year Graduated:   Degree:
Internship:
Name of Program:   Speciality:   Year Graduated/Attended:
Externship:
Name of Program:   Speciality:   Year Graduated/Attended:
Please list any professional honours, awards, publications or research:
Relevant work experience:
Your native language:
Your language skills:
Language 1:
Language 2:
Language 3:
Language 4:
Current position:
Position you are applying for:
Include any military experience, internship/externship which may relate to the position for which you are applying:
Type of work (select any/all):
Short Term Contract
Long Term Contract
Permanent Position
Date available: - - Duration available year(s)
Have you ever worked abroad? yes no, If yes, Country and Duration

 Medical Registration (Licences): 
Please list all medical registrations (licences, certificates) that you have obtained or are obtaining
Medical certificate/licence:   Date of issue:   Current status of certificate/licence:
Medical certificate/licence:   Date of issue:   Current status of certificate/licence:
Medical certificate/licence:   Date of issue:   Current status of certificate/licence:
Medical certificate/licence:   Date of issue:   Current status of certificate/licence:
Medical certificate/licence:   Date of issue:   Current status of certificate/licence:
 Professional References: 
A total of 3 references are required! Two of them must be in your field of specialization and the last one must have worked with you within the past few months.
Name of Reference:
 Title or Field of Specialization:
 Phone (Home/Work):
 E-mail:
Name of Reference:
 Title or Field of Specialization:
 Phone (Home/Work):
 E-mail:
Name of Reference:
 Title or Field of Specialization:
 Phone (Home/Work):
 E-mail:

 Questionnaire: 
What is motivating your decision to leave your current job?
Describe in detail what you would be doing in your ideal next position. What technology would you work with, whom would you report to and what types of projects would you be working on:
Have you ever been the subject of any medical defence, claims, incidences or allegations? yes no
Have you ever been denied a license or had your license limited, suspended or revoked to practice? yes no
Have you ever been discharged or requested to resign from any employment? yes no
Are you now or have you ever been under the supervision of a doctor for any emotional, psychological or other conditions or illnesses which might have an impact on your performance as a doctor? yes no
Do you or any family member who will accompany you, have any diseases or disabilities that might preclude you from receiving an entrance visa to Denmark on medical grounds? yes no, if yes, please specify:
Did you ever have a criminal record? yes no
Are you now or have you ever been addicted to any drugs and alcohol? yes no
Are you HIV or HEP B positive? yes no
Are you smoker? yes no
Your strengths and weaknesses:
Supplementary Comments:

 Authorization: 
I certify that the given information on this application form is true, complete and correct. I understand that any incorrect or forged information made by me, may involve into the immediate termination of any contractual relationship.
I also recognize that during the search and selection process between clients and candidates, Int. Rec. Agency NIKA has expended considerable amounts of time, money and energy.
I authorize International Recruiting Agency NIKA to speak to my references, research my background if needed and share any information obtained with Agency's clients.
I further understand that acceptance of this application is no guarantee of employment.

All information, collected from this form, will only be used in connection with occupation of this specific position and will not be given,
sold or shared with any other external organisations.

!!! IMPORTANT !!!
Did you remember to attach your current CV/resume in STEP ONE above?
STEP TWO click Submit button to send a second email with your profile information.

Please click only once and wait for the confirmation page, as it may take a minute to complete the process.