Nurse Practitioner Job Application
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Employment Type
*
Full-time
Part-time
PRN
Any of the above
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Licensure & Credentials
Are you currently licensed as an NP in Louisiana?
*
Yes
No
License number
Expiration date
-
Month
-
Day
Year
Date
Certifying Body
*
AANP
ANCC
Other
Population Focus
*
FNP
AGNP
PNP
PMHNP
Other
If you chose other, please specify:
DEA Registration
*
Active
In process
Not currently
Expiration date
-
Month
-
Day
Year
Date
NPI number
*
BLS Certification
*
Active
Expired
Not applicable
Expiration date
-
Month
-
Day
Year
Date
ACLS Certification
*
Active
Expired
Not applicable
Expiration date
-
Month
-
Day
Year
Date
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Experience
Years of NP experience
*
Please Select
0-1
2-4
5-9
10+
Primary Care Experience
*
Yes
No
Brief Summary of Clinical Background
*
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Availability
Earliest Start Date
*
-
Month
-
Day
Year
Date
Availability / Preferred Schedule
*
Weekdays
Weekends
Afternoons
Flexible
Are you willing to commute to Jonesville, Louisiana?
*
Yes
No
Maybe
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Upload Information
Please upload Resume & CV
*
Browse Files
Drag and drop files here
Choose a file
(allowed files: pdf, doc, docx)
Cancel
of
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References
Reference 1
*
First Name
Last Name
Phone number
*
Please enter a valid phone number.
Relationship
*
Reference 2
*
First Name
Last Name
Phone number
*
Please enter a valid phone number.
Relationship
*
Reference 3
*
First Name
Last Name
Phone number
*
Please enter a valid phone number.
Relationship
*
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Consent & Submit
“I certify that the information I submitted is accurate to the best of my knowledge and I authorize Delta Med Clinic to contact me regarding this application.”
*
Yes
Privacy + applicant notice
Applicant Privacy Notice: Information submitted will be used only for recruitment and hiring. Please do not include your medical information in this application.
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