All of the forms in this section MUST be received by Surgical Exchange before we can process your application. Please use the online version when available to avoid delays. If an online version is not listed for a form, please print the PDF version and fax the completed application to Surgical Exchange (our fax number is printed at the top of each form).

You must complete a checklist for each position for which you are qualified and would like to be considered. Where available, please use the online form version of the checklist to avoid processing delays. The Job Summaries provide detailed descriptions of the requirements for positions.

Ambulatory Care

• Checklist (Online Form)
• Checklist (PDF)

Certified Nurse Aide

• Checklist (Online Form)
• Checklist (PDF)

Emergency Medical Technician (EMT)

• Checklist (Online Form)
• Checklist (PDF)

Medical Assistant (Front Office)

• Checklist (PDF)
• Job Summary (PDF)

Medical Assistant (Back Office)

• Checklist (PDF)
• Job Summary (PDF)

Please print this SUPPLEMENTAL FORMS PDF and fax the completed form to Surgical Exchange (our fax number is printed at the top of the form). The individual forms listed below are included in the Supplemental Form PDF .

• HIPAA Federal Regulation Policy
• Annual Inservices
• Age Appropriate Care Proficiency Checklist
• Educational Record
• Attestation Form
• Orientation Skills Post-Test
• Policy for Elimination of Artificial Nails

Below are links to the IRS and USCIS sites where you can complete a W-4 and/or I-9 form, as applicable. Selecting these links will open a new window. Be sure to return to the Surgical Exchange website to complete the application process.

• W-4 (English): http://www.irs.gov/pub/irs-pdf/fw4.pdf
  
• W-4 (Spanish): http://www.irs.gov/pub/irs-pdf/fw4sp.pdf
• I-9 form (English): http://www.uscis.gov/files/form/I-9.pdf
• I-9 form (Spanish): http://www.uscis.gov/files/form/I-9Span.pdf

In compliance with applicable laws, our company does not discriminate because of age, sex, race, color, religion, marital status, national origin, veteran status, or disability.

HIPPA Regulation: Healthcare and Health Plan Professional Compliance. As a representative of Surgical Exchange, you have the responsibility to protect all patients' medical information so that it is not improperly used or disclosed, in accordance with federal and state law.

* The online application is hosted on a secure server, but if online security remains a concern for you, please use the printable PDF version of the application form.

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