SCI Provider Application Please enable JavaScript in your browser to complete this form.PERSONAL INFORMATIONFull Legal Name *Maiden NameEmail *Phone *Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeMarital Status *Select OneMarriedSingleN/ABirthdate *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Place of BirthSocial Security NumberHave you ever spoken with a member of our team before? *YesNoRecruiter NameHow did you hear about us? EDUCATION INFORMATIONMedical SchoolMedical School - Date of CompletionSpecialtyResidencyResidency - Date of CompletionFellowshipFellowship - Date of CompletionUndergraduate ProgramGraduate Program LICENSUREDo you have an active DEA license? *YesNoN/AAre you board certified? *YesNoN/AStates Licensed *AlabamaAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingDesired Locations *AlabamaAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingLicenses PendingDo you carry your own malpractice insurance? *YesNo CERTIFICATIONSCERTIFICATIONSBLS *YesNoPALS *YesNoOTHER *YesNoACLS *YesNoNALS *YesNo REFERENCESReference 1Reference 1Reference Name *Position *Phone *Email *Reference 2Reference 2Reference Name *Position *Phone *Email *Reference 3Reference 3Reference Name *Position *Phone *Email * JOB PREFERENCESTell us about your ideal job settingPreferred shiftsWhat positions are you interested in?Locum TenensLocum TenensPRNLocum Tenens & PRNWhen are you available?How long of an assignment are you looking for?How far are you willing to travel for your next assignment? ATTESTATION QUESTIONS If you answer yes to any of the following, please provide an explanation, along with any necessary supporting documents. Please use the File Upload feature at end of form to upload any supporting documents.Do you have any physical conditions that may limit or hinder your performance in the position for you are applying? *YesNoExplanation *Have you ever been convicted of a felony, misdemeanor, or crime other than a traffic violation? *YesNoExplanation *Have your privileges at any healthcare facility ever been voluntarily or involuntarily relinquished, denied, or suspended? *YesNoExplanation *Have you ever been the subject of disciplinary proceedings at any healthcare facility? *YesNoExplanation *Has your license or certification in any state ever been voluntarily or involuntarily relinquished, suspended, or terminated? *YesNoExplanation *Have you ever been the subject of disciplinary proceedings or investigation by any state licensure board? *YesNoExplanation *Have you ever been suspended, terminated, sanctioned, or otherwise restricted from any health insurance program? *YesNoExplanation *Have you ever been named in, or had any past/pending judgments made against you in a professional malpractice liability case? *YesNoExplanation * DOCUMENTS & FILESPlease upload a document or zipped folder containing your CV or resume, and additional supporting documents requested by your recruiter or SCI Credentialing Department. Total files uploaded must be less than 5MB, allowed file types are zip, pdf, doc, docx, rtf, jpg.Document Upload Click or drag files to this area to upload. You can upload up to 5 files. STATEMENT OF AUTHORIZATION & RELEASE *AgreeI certify that my answers are true and complete. If this application leads to employment, I understand that false or misleading information in my application may result in my dismissal. SCI Anesthesia Services, and its representatives are hereby authorized to make any investigations of my personal and professional history through any agency or bureau necessary, including verification background checks, E-verify, degree verifications, insurance claims history requests, loss run requests, and transcript requests from my educational institutions. SCI Anesthesia Services is also authorized to investigate my ability, employment records or character through inquires to individuals and/or employers mentioned in this application. I hereby agree that this authorization and appointment shall be valid until revoked by me in written revocation delivered to SCI Anesthesia Services. I hereby release SCI Anesthesia Services and the person(s) to whom the inquiry is made from any and all claims and liability growing out of such inquiries, and consent to the release of such information. Submit