LOS ANGELES COUNTY - DHS Provider Application Form

Physician Specialist

APPLICANT INFORMATION

Position Title Physician Specialist Exam No Y5476E

Name^*

First Name

Middle Name

Last Name

Address^*

Mailing Address (max. 100 chars.)

City

State

Zip Code

Phone Number^*

Primary

Alt.

Email Address^*

Primary

Alt.

Social Security #^*

_{(last 4, ok)}

PROFESSIONAL INFORMATION

Licensed Healthcare Provider in California

Medical License (CA)

License No.

Expiry Date

DEA Certification No

Area of Practice

Specialty

Other

Certifying Board (Primary)

Board Certified

Certifying Board (Additional)

Specialty

(Additional)

(Other)

Area of Practice

Specialty

Certifying Board

ADDITIONAL INFORMATION

Residency or Training Program Completed

Date completed or will complete residency or training program

*Candidates who have not completed residency/training will be placed on WITHHOLD STATUS until completion date.

Preferred Work Location/Environment

Targeted Area Of Interest

Preferred

Additional

Preferred Employment Type

Current Employee of County of Los Angeles

Employee No.

Veteran of the US Armed Forces

*Candidates marking ‘Yes’: please include a copy of your DD214, Certificate of Discharge or Separation from Active Duty, or other official document(s) issued by your branch of service.

Language (other than English)

Additional Languages Spoken

Other

Do you read and write the languages selected above?

REQUIRED DOCUMENTS

Attach the following required documents:

Curriculum Vitae / Resumé
Statement of Career Goals
Legible copy of certificate of completion of residency/training program approved by a nationally recognized Board
Legible copy of Physician & Surgeon Certificate
(If applicable) – Copy of your DD214 Certificate of Discharge or Separation from Active Duty

Any missing information from the above list will be considered an incomplete application and may be rejected. Additionally, an application may be rejected if information is submitted by someone other than applicant.

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REFERRAL INFORMATION

How did you hear about this position?

Source^*

Other

ACCEPT AND CONTINUE

By clicking on the "Accept & Submit" button, I certify that all information and statements made in this application and any attachments pertaining thereto are true and complete to the best of my knowledge. I understand and agree that any false information and/or statement(s) of a material facts or omissions may subject me to disqualification or dismissal.

PRINT YOUR COMPLETE LEGAL NAME:

DATE:

Los Angeles County Health Agency Provider Recruitment

Physician Specialist

APPLICANT INFORMATION

PROFESSIONAL INFORMATION

ADDITIONAL INFORMATION

REQUIRED DOCUMENTS

REFERRAL INFORMATION

ACCEPT AND CONTINUE