The Whittaker Group LLC.

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Professional Profile

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PERSONAL
Name
PrefixFirstLastSuffix
Phone (Home)
Use Format: (###)###-####
Phone (Cell)
Use Format: (###)###-####
Home Address
Street AddressCityStateZIP Code
Email (Home)
Are You Interested In Relocating?
- Yes
- No
Where Would You Like To Relocate To?
Which Locations Will You NOT Consider?
Are You Willing To Travel?
- Yes
- No
How Much Traveling?
- 10 - 20%
- 20 - 30%
- 30 - 50%
- 50% +

EMPLOYMENT
Current Title
Employer
Email (Work)
Type of Facility & Number of Licensed Beds
Gross Revenue
Use Format: ###,###.##
Responsibilities/Duties
Next Promotable Position
Who Do You Report To?
Enter Name & Title
Management: Level of and Number of Staff that You Manage:
Why Would You Want to Leave?
What Factors Will Influence Your Acceptance of an Offer?

COMPENSATION
Current Salary
Use Format: ###,###.##
Bonus
Use Format: ###,###.##
Minimum Salary Agreeable
Use Format: ###,###.##

ACADEMIC CREDENTIALS
Education
University: Degree: Year Earned: University: Degree: Year Earned: (Enter More Schools As Needed).

CAREER ASSESSMENT
Areas of Skills/Expertise:
Please Describe Your Ideal Position in Terms of Title, Responsibilities, Organization Size and Type:
What Are Your Career Goals?
Are There Any Specific Organizations That You Would Like To Consider?
Are You Interested In Consulting?
- Yes
- No
Would You Consider A Temporary/Contract Assignment?
- Yes
- No
What Are Your Greatest Accomplishments In The Past Five (5) Years?
Computer/Software Skills:
How Did You Hear About The Whittaker Group?
- Friend or Colleague
- Web Search
- Advertisement
- Other (Specify Below)
Other: Please Specify Below
Which Organizations/Recruiting Agencies, Have You Interviewed With or Sent Your Resume to Within the Past Two (2) Years?
Additional Comments:
I certify that the facts contained in this instrument are true and complete to the best of my knowledge. I hereby authorize investigation of all statements contained herein to provide all necessary information concerning my previous employment and any pertinent information that they may have. I release all parties from all liability for any damage.
- I Agree
- I Do Not Agree

REFERENCE AUTHORIZATION
The Whittaker Group is an executive search and recruitment firm registered in the State of Michigan and operate under its laws and stat- utes. As our clients ask us to check references on you, we are required to have you complete and sign this form indicating that you are aware of your rights under the law. The Whittaker Group will not contact your present employer without your consent.
REFERENCE #1 of 4
Name
PrefixFirstLastSuffix
Title
Relationship To You
Facility
Facility Address
Street AddressAddress Line 2CityStateZIP Code
Business Phone
Use Format: (###)###-####
Home Phone
Use Format: (###)###-####
Email

REFERENCE #2 of 4
Name
PrefixFirstLastSuffix
Title
Relationship To You
Facility
Facility Address
Street AddressAddress Line 2CityStateZIP Code
Business Phone
Use Format: (###)###-####
Home Phone
Use Format: (###)###-####
Email

REFERENCE #3 of 4
Name
PrefixFirstLastSuffix
Title
Relationship To You
Facility
Facility Address
Street AddressAddress Line 2CityStateZIP Code
Business Phone
Use Format: (###)###-####
Home Phone
Use Format: (###)###-####
Email

REFERENCE #4 of 4
Name
PrefixFirstLastSuffix
Title
Relationship To You
Facility
Facility Address
Street AddressAddress Line 2CityStateZIP Code
Business Phone
Use Format: (###)###-####
Home Phone
Use Format: (###)###-####
Email

CONCLUSION
Have You Ever Been Convicted of a Felony?
- Yes
- No
If Yes, Please Describe Below:
I understand that an investigative report which may include information concerning my characteristics, modes of living, and financial re- sponsibility may be obtained by prospective employers for evaluation and that I have the right to make request to the designated agency to learn the complete nature and scope of this investigative report.
- I Agree
- I Do Not Agree
Date of Agreement
Thank You!
Upon submitting this form to us, you will receive a copy of all information submitted via the email address you provided.

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