NP Fellowship Online Application

Application to Community Healthcare Network's NP Fellowship Program

Please fill in the form carefully and make sure all information is accurate
Which program are you applying to?*
Applicant Information
Name*

First NameLast Name
Other Names Used
Date of Birth*

MonthDayYear
Gender*

MaleFemaleN/AOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number*
E-mail*
example@example.com
Additional Information

for federal reporting purposes
Race*
Ethnicity*

HispanicNon-Hispanic
Languages spoken*
Active or Retired Military Personnel*

YesNo
Which branch?*
Disadvantaged background*
Are you an applicant who has (and whose spouse, if any, has) characteristics that indicate a higher likelihood of continuing to practice in a HPSA after the service obligation is completed, and who comes from a disadvantaged background? You must submit certification on the NHSC-approved form from your school that you: (i) were identified as having a “disadvantaged background” based on environmental and/or economic factors, or (ii) received a federal Exceptional Financial Need Scholarship.
Nurse Practitioner Information
Federal DEA Number*
If you have not graduated, put N/A.
Expiration Date*

MonthDayYear
Date
National Provider Identifier (NPI) *
If you have not graduated, put N/A.
Board Certification *
Applicants must be Board Certified OR Board certified by the start of the program.
Expiration Date*

MonthDayYear
Date
If not certified, have you been accepted by the board to take the examination and are you actively in the board certification process?*

YesNo
If yes, indicate planned examination date. *

MonthDayYear
Date
Have you ever taken and failed a certification examination?*

YesNo
If yes, please explain.*
Any other certifications or memberships?*
Academic Appointments (Example: Professor at University) *
From*

MonthDayYear
Date
To*

MonthDayYear
Date
Practicing Specialty (either formal certifications or significant practice experience) *
Primary
Secondary
Essay Questions

Please choose three of the five questions below to respond to. You may answer them separately or combine into one essay. Answer must be no more than 2 pages total.
1. Describe how your personal life experiences or educational experiences will contribute to CHN’s mission of providing access to quality, culturally competent and comprehensive community based healthcare.
2. Part of the goal of the CHN NP Fellowship is to address the healthcare disparities that face NYC. How do you foresee yourself helping to address the healthcare challenges that affect communities in NYC?
3. Why do you think you will be an asset to Community Healthcare Network’s NP Fellowship?
4. While providing healthcare as a Nurse Practitioner is often a rewarding career, it is also a profession that entails addressing constant challenges. What do you see as the most significant issues the NP profession will face in the next 20 years, and what are some potential solutions for these problems?
5. Briefly describe your short-term and long-term professional goals. Where do you see yourself in 10 years?
Please upload essay submissions here (pdf, doc, docx).*

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Required Documentation
CV in month/year format (include previous clinical rotations)*

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Copy of State Issued ID*

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If not board certified at the time of application, please provide 3 professional letters of recommendation. If board certified at the time of application, 2 letters of recommendation. Letters must:
- Be dated, signed and addressed to Dr. Taisha Benjamin, Chief Medical Officer.
- Include 1 letter from a nursing education program, 1 letter from employment, and 1 of your choosing.*
* If more than 5 years post-graduation, 1 letter can be from your current supervisor (in lieu of education program), and 1 from your general employment
Please upload letters of recommendation here (pdf, doc, docx).*

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My Products*
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Registration Fee
$50.00 Quantity

Total

$0.00
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Application to Community Healthcare Network's NP Fellowship Program

Applicant Information

Additional Information

Nurse Practitioner Information

Essay Questions

Required Documentation