Psychiatric Nurse Practitioner Employment Application 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Full Name Street Address State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming City ZIP Phone Email Position Applying For PMHNP FNP Other Are You Seeking Full-time Part-time PRN Other Preferred Start Date State(s) in Which You Hold an NP License (Hold CTRL/CMD to select multiple options) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming NP License Number(s) License Expiration Date(s) Do You Have a DEA License? Yes No If yes, which state(s)? Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming DEA License Number DEA Expiration Date National Provider Identifier (NPI) Number Are You Currently Board Certified as a PMHNP? Yes No If no, are you board-eligible? Yes No 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? Yes No If yes, please describe Are You Currently Under Peer Review or Disciplinary Action by Another Healthcare Facility or a State Licensing Board? Yes No If yes, which facility/board? Have You Ever Been Terminated from Employment? Yes No If yes, please explain Have You Ever Had a Malpractice Lawsuit Filed Against You? Yes No If yes, please describe Were Any Lawsuits Settled Out of Court? Yes No If yes, please describe Have you ever been charged with or convicted of any crime, or are there any pending investigations against you? Yes No If yes, please describe Do You Have Any Current or Past History of Substance Abuse? Yes No If yes, please describe Do You Have Any Physical or Mental Condition Preventing You from Performing NP Duties? Yes No If yes, specify prior/current treatment or accommodations Do You Have Your Own Malpractice Insurance? Yes No Coverage limits (if applicable) Do You Have a Collaborative Psychiatrist or Supervising MD (If Required by Your State)? Yes No Not Applicable Please provide two professional references (e.g., current or former supervisors, colleagues, mentors). Reference #1 Name Role/Relationship Organization Phone Email Length of Time Known Reference #2 Name Role/Relationship Organization Phone Email 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. Send
