Advantage Locums | Locum Tenens with Advantages!

Application


	Applicant Profile

Fields marked with an asterisk (*) are required.

* First Name	Middle Name	* Last Name

* Home Phone	Mobile Phone	Work Phone
- -	- -	- -

Address	City	State	ZIP Code
			-

* Email Address	Social Security #
	- -

Are you eligible to work as an independent contractor in the United States? Yes No

Emergency Contact Name	Emergency Contact Phone	Relationship
	- -


	Preferences

Specialty	Geographic Preference	Preferred Practice Setting

Date of Availability	Preferred Length of Assignment	Best time to contact you
/ /


	Certification


Original Exam	State	#Times Taken	Date Passed
			/ /

Other Exam		# Times Taken	Date Passed
			/ /

Other Exam		# Times Taken	Date Passed
			/ /


National Board ID#	Date Passed
	/ /


Board Eligible?	Eligible Board Name
Yes No

Certified By American Board of:


Date Certified	Date recertified	Expiration Date
/ /	/ /	/ /


BCLS Exp. Date	ATLS Exp. Date	ACLS Exp. Date	APLS Exp. Date
/ /	/ /	/ /	/ /


	State Licensure and Registration


Active State Licenses

	State	License Number	Date Issued	Date Expires
1.			/ /	/ /

	CSR#	CSR Exp. Date
		/ /


	State	License Number	Date Issued	Date Expires
2.			/ /	/ /

	CSR#	CSR Exp. Date
		/ /


	State	License Number	Date Issued	Date Expires
3.			/ /	/ /

	CSR#	CSR Exp. Date
		/ /


	State	License Number	Date Issued	Date Expires
4.			/ /	/ /

	CSR#	CSR Exp. Date
		/ /


	State	License Number	Date Issued	Date Expires
5.			/ /	/ /

	CSR#	CSR Exp. Date
		/ /


NPI#	ECFMG#


DEA#	Date Issued	Date Expires
	/ /	/ /


Original License State	List all inactive state licenses


	Education


Undergraduate Education (From and To dates are in M/CCYY format)
School	From	To
	/	/
Street	City	State	ZIP Code
			-
Degree


Medical Education
School	From	To
	/	/
Street	City	State	ZIP Code
			-
Degree


Other Graduate Education
School	From	To
	/	/
Street	City	State	ZIP Code
			-
Degree


Internship
Institution	From	To
	/	/
Street	City	State	ZIP Code
			-
Type		Director


Residency
School	From	To
	/	/
Street	City	State	Postal Code
			-
Type		Director


Fellowship
School	From	To
	/	/
Street	City	State	ZIP Code
			-
Type		Director


	References


Please list at least three professional references who have experience working with you.

1.	Name	Association

	Specialty	Phone
		- -

2.	Name	Association

	Specialty	Phone
		- -

3.	Name	Association

	Specialty	Phone
		- -

4.	Name	Association

	Specialty	Phone
		- -

5.	Name	Association

	Specialty	Phone
		- -

6.	Name	Association

	Specialty	Phone
		- -


	Disciplinary Action


	Professional Liability


Insurance Carrier	Amount of Coverage	Expiration Date
		/ /


Policy Number	Agent	Phone Number
		- -


	Authorization to Release

I certify that the information on this application is true and complete to the best of my knowledge. I authorize Advantage Locums, LLC to release information contained in this application, or obtained by Advantage Locums, LLC pursuant to its credentials verification processes also authorized by this paragraph, to its Clients, and to query the NPDB, DEA, AMA, FACIS, FSMB, insurance companies, and medical facility clients. I waive any claims I might otherwise have against Advantage Locums, LLC for releasing information as authorized by this paragraph. I release Advantage Locums, LLC and/or its agents and any person or entity, which provided information pursuant to the Authorization for Obtaining Consumer and Investigative Consumer Reports from any and all liabilities, claims or lawsuits in regards to the information obtained from any and all above referenced sources used. I understand that all or part of this information, including my social security number may be released to clients as part of the hiring process, and agree to release of any part or all of this information, including my social security number.


* Applicant Name	* Application Date
	/ /


	Independent Contractor Acknowledgment

I declare that I am a trained and licensed medical professional engaged in the practice of medicine. When providing medical services to patients at contracted healthcare facilities I am solely responsible for my decisions and professional actions, and in no way does Advantage Locums, LLC direct or control the manner in which I practice my profession. I understand Advantage Locums, LLC is not engaged in the practice of medicine, and is solely a staffing and placement agency. As an independent contractor, I declare I am not employed by Advantage Locums, LLC and I am not entitled to claim unemployment benefits or workers compensation benefits against Advantage Locums, LLC. I may terminate my relationship with Advantage Locums, LLC at any time and may cancel an active assignment with or without cause by providing 30 days written notice. Further, I am not directed by Advantage Locums, LLC to accept any assignment and agree that I independently determine the assignments I accept and the rate I will charge for my service. I understand I am responsible for paying all federal, state, and local income taxes due on income earned from my work as an independently contracted medical professional.


* Contractor Name	* Contractor Date
	/ /

Save your work so you can update or complete it later	Submit your information via email

Advantage Locums is a proud member of the
National Association of Locum Tenens Organizations
and National Association of Physician Recruiters.

About Us | Physicians | Healthcare Facilities | Contact Us | Apply NOW!


		If yes, how many?
1. Have there been, or are there any current pending investigations, incidents, claims, suits, settlements, or arbitration proceedings involving alleged malpractice relating to your professional practice?	Yes No
2. Have any of your malpractice suits ever been dismissed, settled, or closed without payment?	Yes No
3. Have any of your malpractice suits ever been dismissed, settled, or closed with payment?	Yes No
4. Are you currently the subject in any pending medical malpractice claimes or suits?	Yes No
5. Has your malpractice insurance ever been denied or limited?	Yes No	N/A


If the answer is "Yes" to any of the following questions, please give an explanation in the box below
1.	Has your medical license to practice medicine or any other license or registration, in any jurisdiction ever been denied, put on probation, limited, suspended, revoked, or surrendered?	Yes No
2.	Has your request for any specific clinical privileges or academic appointments ever been denied or granted with limitations?	Yes No
3.	Have your clinical privileges at any healthcare facility ever been suspended, revoked, diminished, refused, not renewed, or surrendered?	Yes No
4.	Have you ever been denied membership or renewal thereof or been subject to disciplinary action by a medical organization?	Yes No
5.	Have you ever been the subject of an investigation by any private or government agency concerning you participation in any Medicare or Medicaid program?	Yes No
6.	Have you even been the subject of any other professional sanctions not documented above?	Yes No
7.	Have you even been or are you currently involved in any illegal drug use?	Yes No
8.	Have you ever been convicted of or are you currently under investigation of a felony charge?	Yes No

Explanation: