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AFC Urgent Care Florham Park, NJ

Please fill in all required (*) fields below, and attach your CV at the end of the form.

Contact Info

First Name *

Last Name *

Street Address - Line 1 *

Street Address - Line 2

City *

State *

Zip Code *

Tel# as (111) 222-3333 *

Email Address *

Please re-enter email *

Professional Qualifications

Where did you attend medical school? *

US

Overseas

Year graduated from medical school? *

Year of ECFMG/USMLE Certification?

Are you authorized to work in the U.S.? *

Yes

No

If not, authorization is expected (MM/YYYY)

Do you have a current NJ license? *

Yes

No

Indicate your certifications below: *

What type of engagement are your seeking? *

10-20 hrs/week

20-30 hrs/week

30-40 hrs/week

When are you available to start? * +

What is your availability? *

Weekdays only

Weekends only

Flexible

Indicate your current Board status and years of post-residency experience related to your specialty.

Specialty #1 *

Cert. Level *

Related Experience *

Add a second specialty?

Check to add field

Specialty #2 *

Cert. Level *

Related Experience *

Personal Background (for malpractice eligibility)

Have you ever been terminated from employment or contract work? *

Yes

No

Have you ever been convicted of a crime? *

Yes

No

Have you ever been involved in substance abuse? *

Yes

No

Please note that we require all medical staff to undergo pre-employment drug screening, have all credentials, licenses and certifications verified, and backgrounds checked for criminal violations. Do you object to providing your consent for any of the above tests, checks and verifications? *

Yes

No

Have you ever been denied medical malpractice insurance? *

Yes

No

Have you ever been involved in a malpractice claim? *

Yes

No

Please provide more information in

the Malpractice Claims section below

Malpractice Claim(s): Briefly report case(s), any judgments, and resolutions, including dates.

Comfort Zone

Are you proficient in treating fractures? *

Yes

Somewhat

No

Are you proficient in treating lacerations? *

Yes

Somewhat

No

Are you comfortable treating infants/children? *

Yes, all ages	Yes, ages 1+	Yes, ages 2+
No

Are you comfortable treating seniors? *

Yes

No

Are you comfortable reading x-rays for diagnosis? *

Yes

No

Are you comfortable reading EKGs for diagnosis? *

Yes

No

Final Step: Submit CV / Resume

CV / Resume (PDF or Word files, max. size 512KB) *

<< PLEASE UPLOAD YOUR CV/RESUME

<< BEFORE YOU CLICK SUBMIT BELOW.

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