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Step 1
Provider Information
First name
*
Last name
*
Discipline
*
MD
DO
CRNA
Nurse Practitioner
Physician Assistant
Home Address
Address Line 1
*
Address Line 2
City
*
State
*
Zip Code
*
Contact Details
Email
*
Phone
*
Mobile
*
Opt in for text notifications (including new Locum job openings)
Birth Details
Date of Birth
*
Place of Birth
*
Board Certifications
Board Certified?
*
Yes
No
Medical Board
Certification Date
NPI#
*
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Step 2
Licenses (add as many as needed)
State
Number
Date Issued
Expiry Date
State
Number
Date Issued
Expiry Date
Add License
DEA & CSR (add as many as needed)
State
Number
Date Issued
Expiry Date
State
Number
Date Issued
Expiry Date
Add DEA & CSR
Certifications (add as many as needed)
State
Number
Date Issued
Expiry Date
State
Number
Date Issued
Expiry Date
Add Certificate
Education (add as many as needed)
Specialty
*
School
Field of Study
Degree
Start Date
End Date
Address
City
State/County/Province
Zip/Postal Code
Specialty
*
School
Field of Study
Degree
Start Date
End Date
Address
City
State/County/Province
Zip/Postal Code
Add Education
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Step 3
Employment (do not leave blanks in history)
Facility
Job Title
Start Date
End Date
Reason for Leaving
Address
City
State/County/Province
Zip Code/Postal Code
Facility
Job Title
Start Date
End Date
Reason for Leaving
Address
City
State/County/Province
Zip Code/Postal Code
Add Employment
Please explain any gaps more than 30 days using month and date
Reference (at least 3 required)
Name
*
Institution
*
Phone
*
Email
*
Relationship
*
Name
*
Institution
*
Phone
*
Email
*
Relationship
*
Name
*
Institution
*
Phone
*
Email
*
Relationship
*
Name
*
Institution
*
Phone
*
Email
*
Relationship
*
Add Reference
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Step 4
What was the date of your last patient contact
*
Have you ever had your license or privileges investigated, placed on probation, suspended, denied or revoked?
*
Yes
No
Have you ever been accused of criminal activity, treated for substance abuse, or accused of sexual misconduct?
*
Yes
No
Have you ever been named in a malpractice claim?
*
Yes
No
Are you aware of any incident reporting on the FSMB or NPBD?
*
Yes
No
If answered "yes" to any of the prior questions, please explain:
I acknowledge I have read and agree to all terms and conditions listed below
*
I have read and fully understand the questions asked in this application and that all answers given by me are true, accurate and complete. I also understand that the omission, concealment or misrepresentation of any facts on this application or during the interview process for any position with Era Locums can be grounds for immediate privileging, licensing, and credentialing application withdrawal and/or cancellation of assignment. I understand this application is considered a legal document. The acceptance of terms and submission of this application acts as my signature and acceptance of aforementioned terms herein.
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