First Name*
 
 
Last Name*
 
 
 
Phone Number
 
 
Email Address*
 
 
 
Social Security Number (no dashes)*
 
 
 
 
Street 1
 
 
City
 
 
State
 
 
License number (NIPR)
 
 
 
 
License effective date
 
 
 
 
License termination date
 
 
 
 
State of licensure
 
 
 
 
AHIP certificate*
 
Yes
No
 
 
 
Do you have a health producer's license?*
 
Yes
No
 
 
 
If you answered yes to the above question please complete this section.
Consent for background check*
 
Yes
No
 
 
Consent for drug screen + results*
 
Yes
No
 
 
Attach Resume
 
 
 
 
Section title
 
 
Attach completed background check form.