Lumos Consultant Intake Form

First Name *

Last Name *

Email Address *

Contact Number *

Home State *

Are you currently on a project? *

If yes, when is it slated to end? (MM-DD-YYYY) +

Percentage of travel in your ideal role? *

Percentage you are willing to travel? *

Do you prefer W2 or 1099? *

Do you have any restrictions (travel, location, size, etc.) to work on a project? *

If yes, please describe what those restrictions are:

All applications CERTIFIED in:

All applications CREDENTIALED in:

Years of Epic Experience *

Primary Role *

Secondary Role

Resume Upload (.doc, .docx or .pdf) *

Referred by:

Any additional comments: