Employment Form

Psychiatric Nurse Practitioner
Employment Application

Full Name

Street Address

State

City

ZIP

Phone

Position Applying For

Are You Seeking

Preferred Start Date

State(s) in Which You Hold an NP License (Hold CTRL/CMD to select multiple options)

NP License Number(s)

License Expiration Date(s)

Do You Have a DEA License?

If yes, which state(s)?

DEA License Number

DEA Expiration Date

National Provider Identifier (NPI) Number

Are You Currently Board Certified as a PMHNP?

If no, are you board-eligible?

Current or Most Recent Employer

Company Name

Job Title

Date Employed From

Date Employed To

Reason for Leaving (if no longer employed)

Previous Employer's Detail

Additional Details - Prior Positions

Have You Ever Had Your NP License Suspended or Revoked?

If yes, please describe

Are You Currently Under Peer Review or Disciplinary Action by Another Healthcare Facility or a State Licensing Board?

If yes, which facility/board?

Have You Ever Been Terminated from Employment?

If yes, please explain

Have You Ever Had a Malpractice Lawsuit Filed Against You?

If yes, please describe

Were Any Lawsuits Settled Out of Court?

If yes, please describe

Have you ever been charged with or convicted of any crime, or are there any pending investigations against you?

If yes, please describe

Do You Have Any Current or Past History of Substance Abuse?

If yes, please describe

Do You Have Any Physical or Mental Condition Preventing You from Performing NP Duties?

If yes, specify prior/current treatment or accommodations

Do You Have Your Own Malpractice Insurance?

Coverage limits (if applicable)

Do You Have a Collaborative Psychiatrist or Supervising MD (If Required by Your State)?

Please provide two professional references (e.g., current or former supervisors, colleagues, mentors).

Reference #1

Name

Role/Relationship

Organization

Phone

Length of Time Known

Reference #2

Name

Role/Relationship

Organization

Phone

Length of Time Known

I hereby attest that all information provided is accurate to the best of my knowledge. I agree to notify the employer of any changes relevant to the above questions. I also authorize the employer to verify any statements or references herein.

Psychiatric Nurse Practitioner
Employment Application

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Psychiatric Nurse Practitioner Employment Application

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Thank you! Your form has been submitted successfully.

Psychiatric Nurse Practitioner
Employment Application