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?* Yes NoFull Name*Type your full name in this boxEmail* Primary Phone Number*Address* Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 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? Yes NoWhat 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.?* Yes No UnsureIf 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? None Up to 2 years 2-5 years >5 yearsHow long have you transcribed in a hospital enviroment? None Up to 2 years 2-5 years >5 yearsCardiology 0 Less than 1 1-2 3-5 >5Consults 0 Less than 1 1-2 3-5 >5Discharge Summaries (Clinical) 0 Less than 1 1-2 3-5 >5Discharge Summaries (Hospital) 0 Less than 1 1-2 3-5 >5Emergency Department 0 Less than 1 1-2 3-5 >5Endocrinology 0 Less than 1 1-2 3-5 >5ENT 0 Less than 1 1-2 3-5 >5Family Practice 0 Less than 1 1-2 3-5 >5Gastroenterology 0 Less than 1 1-2 3-5 >5General Surgery 0 Less than 1 1-2 3-5 >5Hematology 0 Less than 1 1-2 3-5 >5Hepatology 0 Less than 1 1-2 3-5 >5History & Physicals 0 Less than 1 1-2 3-5 >5Internal Medicine 0 Less than 1 1-2 3-5 >5Nephrology 0 Less than 1 1-2 3-5 >5Neurology 0 Less than 1 1-2 3-5 >5OB/GYN 0 Less than 1 1-2 3-5 >5Oncology 0 Less than 1 1-2 3-5 >5Operative Notes 0 Less than 1 1-2 3-5 >5Ophthalmology 0 Less than 1 1-2 3-5 >5Orthopedics 0 Less than 1 1-2 3-5 >5Physical Therapy 0 Less than 1 1-2 3-5 >5Plastics 0 Less than 1 1-2 3-5 >5Psychology 0 Less than 1 1-2 3-5 >5Pulmonary 0 Less than 1 1-2 3-5 >5Radiology 0 Less than 1 1-2 3-5 >5Rehab (Hospital) 0 Less than 1 1-2 3-5 >5Rheumatology 0 Less than 1 1-2 3-5 >5Urology 0 Less than 1 1-2 3-5 >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 uploadMax. file size: 300 MB.Or paste your résumé in the space providedΔ