AMEDDApplicantWorksheet-July2012-3.doc

First name reference type mark x to one that applies

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First Name: Reference Type: (Mark ‘X’ to one that applies) Middle Name: Friend Neighbor Schoolmate Suffix: Work Associate Other: Reference email address: I don’t know: Reference Address: Street: State: Zip Code: City: Country: Home Phone: Work Phone: Available Day or Night? Day Night Available Day or Night? Day Night Country Code: Country Code: Telephone No.: ( ) - Telephone No.: ( ) - Extension: Extension: 61
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PROFESSIONAL ORGANIZATION(S) Organization Name (i.e. Am. Medical Assoc.) From Date (yyyymmdd) To Date (yyyymmdd) Status (i.e. Current, unrestricted, suspended, withdrawn…) PROFESSIONAL LICENSE(S) List all professional licenses/certifications ever held , even if expired . State (i.e. HI) National License? Y/N License No. (i.e. 01234) License Type (i.e. Registered Nurse) Initial Issue Date (yyyymmdd) Expiration Date (yyyymmdd) Status (i.e. Current, unrestricted, suspended, withdrawn…) PROFESSIONAL PRIVILEGE(S) All information must match professional privilege(s) verification letter(s) submitted. Facility Name: From Date: (yyyymmdd) To Date: (yyyymmdd) Status: Facility Address: Street: State: Zip Code: City: Country: Facility Phone No.: Country Code: Telephone No.: ( ) - Extension: PROFESSIONAL PRIVILEGE(S) Facility Name: From Date: (yyyymmdd) From Date: (yyyymmdd) Status: Facility Address: Street: State: Zip Code: City: City: Facility Phone No.: Country Code: Telephone No.: ( ) - Extension: 62
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MALPRACTICE INSURANCE PROVIDER Provide information for Malpractice Insurance Provider(s) within the past 7 years. Information must match Malpractice Insurance verification letter submitted. Carrier Name: Policy No.: Street Address: City: State: Zip Code: Telephone No.:( ) - Time of Provider Coverage: From Date: (yyyymmdd) To Date: (yyyymmdd) MALPRACTICE INSURANCE PROVIDER Carrier Name: Policy No.: Street Address: City: State: Zip Code: Telephone No.:( ) - Time of Provider Coverage: From Date: (yyyymmdd) To Date: (yyyymmdd) MALPRACTICE CLAIM Case No.: Allegation: Suit Filed? Y/N: Court Date: (yyyymmdd): Claim Status (Closed, Open, Settled or Suit Withdrawn): Disposition Favored: Payment Required? Y/N: Payment Amount: $ Payment Type (Award or Settlement): Detailed Medical Facts: Associated Carrier(s): MALPRACTICE CLAIM Case No.: Allegation: Suit Filed? Y/N: Court Date: (yyyymmdd): Claim Status (Closed, Open, Settled or Suit Withdrawn): Disposition Favored: Payment Required? Y/N: Payment Amount: $ Payment Type (Award or Settlement): Detailed Medical Facts: Associated Carrier(s): ACTIVE DUTY ASSIGNMENT PREFERENCES Complete the information below regarding active duty preferences. First Assignment Preference: Duty Assignment (Location): Area Assignment (AOC-if applicable): Second Assignment Preference: Duty Assignment (Location): Area Assignment (AOC-if applicable): Third Assignment Preference: Duty Assignment (Location): Area Assignment (AOC-if applicable): 63
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