Apply Now FULL

Step 1

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

Medical Board

Certification Date

NPI# *

Step 1/4

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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

Step 2/4

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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

Step 3/4

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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

Have you ever been accused of criminal activity, treated for substance abuse, or accused of sexual misconduct? *

Yes

Have you ever been named in a malpractice claim? *

Yes

Are you aware of any incident reporting on the FSMB or NPBD? *

Yes

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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find your people

Step 1

Provider Information

Home Address

Contact Details

Birth Details

Board Certifications

Step 2

Licenses (add as many as needed)

DEA & CSR (add as many as needed)

Certifications (add as many as needed)

Education (add as many as needed)

Step 3

Employment (do not leave blanks in history)

Reference (at least 3 required)

Step 4

Ready for a whole new era?