AFC Urgent Care - Florham Park, NJ  |  Physician Application Form

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

Contact Info

Professional Qualifications

Where did you attend medical school? *
Are you authorized to work in the U.S.? *
Do you have a current NJ license? *
Indicate your certifications below: *
What type of engagement are your seeking? *
What is your availability? *
Indicate your current Board status and years of post-residency experience related to your specialty.
Add a second specialty?

Personal Background (for malpractice eligibility)

Have you ever been terminated from employment or contract work? *
Have you ever been convicted of a crime? *
Have you ever been involved in substance abuse? *
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? *
Have you ever been denied medical malpractice insurance? *
Have you ever been involved in a malpractice claim? *
Please provide more information in 
the Malpractice Claims section below

Comfort Zone

Are you proficient in treating fractures? *
Are you proficient in treating lacerations? *
Are you comfortable treating infants/children? *
Are you comfortable treating seniors? *
Are you comfortable reading x-rays for diagnosis? *
Are you comfortable reading EKGs for diagnosis? *

Final Step: Submit CV / Resume