Fast Chart Qualification FormStep 1 of 3Please complete each of the following questions. Questions marked with " * " are required. You must complete all required fields before you will be able to submit the form to Fast Chart. Please review our Independent Contractor Requirements before completing this form.Have you read our Independent Contractor Requirements?*YesNoFull Name*Type your full name in this boxEmail* Primary Phone Number*Address* Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country How did you hear about Fast Chart?*Direct Mail (postcard, etc.)Fast Chart Transcriptionist (Please list name in box below)Friend/ColleagueInternet Search Engine (i.e. Google)Magazine AdMTStars.comOtherReferring Fast Chart MT nameTotal hours per week*Sunday*01-23-45-67-8What time Sunday?Monday*01-23-45-67-8What time Monday?Tuesday*01-23-45-67-8What time Tuesday?Wednesday*01-23-45-67-8What time Wednesday?Thursday*01-23-45-67-8What time Thursday?Friday*01-23-45-67-8What time Friday?Saturday*01-23-45-67-8What time Saturday?Have you worked from home before?YesNoWhat is your reason for wanting to work from home?What version of Microsoft Office/Word do you have currently installed?*MS Office 2019MS Office 2016MS Office 2013MS Office 2010MS Office 2007Which version of Windows do you have currently installed?*Windows 10Windows 7OtherWhich type of internet connection do you use?*Cable ModemDSLFiberSatelliteT-1Wireless Broadband (ex: Verizon Wireless)Which edition of the AAMT Book of Style do you have?*1st Edition2nd EditionI do not have a copy of either edition.When will you be available to begin work as an Independent Contractor?*Have you previously performed any work with Fast Chart, Inc.?*YesNoUnsureIf the answer is yes, how long ago?Step 2 of 3Please indicate your level of transcription experience (Number of years) in each field:How much DocQscribe experience do you have?None1-2 years3-4 years>5 yearsHow much EditScript experience do you have?None1-2 years3-4 years>5 yearsHow long have you transcribed in a clinical environment?NoneUp to 2 years2-5 years>5 yearsHow long have you transcribed in a hospital enviroment?NoneUp to 2 years2-5 years>5 yearsCardiology0Less than 11-23-5>5Consults0Less than 11-23-5>5Discharge Summaries (Clinical)0Less than 11-23-5>5Discharge Summaries (Hospital)0Less than 11-23-5>5Emergency Department0Less than 11-23-5>5Endocrinology0Less than 11-23-5>5ENT0Less than 11-23-5>5Family Practice0Less than 11-23-5>5Gastroenterology0Less than 11-23-5>5General Surgery0Less than 11-23-5>5Hematology0Less than 11-23-5>5Hepatology0Less than 11-23-5>5History & Physicals0Less than 11-23-5>5Internal Medicine0Less than 11-23-5>5Nephrology0Less than 11-23-5>5Neurology0Less than 11-23-5>5OB/GYN0Less than 11-23-5>5Oncology0Less than 11-23-5>5Operative Notes0Less than 11-23-5>5Ophthalmology0Less than 11-23-5>5Orthopedics0Less than 11-23-5>5Physical Therapy0Less than 11-23-5>5Plastics0Less than 11-23-5>5Psychology0Less than 11-23-5>5Pulmonary0Less than 11-23-5>5Radiology0Less than 11-23-5>5Rehab (Hospital)0Less than 11-23-5>5Rheumatology0Less than 11-23-5>5Urology0Less than 11-23-5>5Do you have experience in specialties that are not listed? If so, list them in the space providedStep 3 of 3Please upload your résumé OR paste it in the allotted area belowChoose a résumé file to uploadOr paste your résumé in the space providedΔ