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Apply for Substitute and/or Associate Position
**Starred fields are only required for those located in North America
Prefer:
Your Name:
Address:
Country:
City:
*State/province:
*Zip:
SSN:
DOB:
E-mail:
Home Phone #:
Cell #:
Office Phone #:
Other:

Education & Training
Undergraduate-
School:
Country:
City:
*State/province:
Graduation Date:
 
Chiropractic-
School:
Country
City:
*State/province:
Graduation Date:
*Use expected date if still attending
 
Techniques:
Languages:

Employment History
Please list a 5 year employment history below including your work history for the past 5 years, even if non-chiropractic employment.
Employer:
Supervisor:
Address:
From:
To:

Employer:
Supervisor:
Address:
From:
To:

Employer:
Supervisor:
Address:
From:
To:

License Information
List each current or previously held license. Fax or e-mail (in word format) a copy of each license renewal card.
State:
#:
Exp. Date:
State:
#:
Exp. Date:
State:
#:
Exp. Date:
Part Four National Board?

Professional Liability Insurance
Fax or e-mail (in word format) a copy of current policy declaration page showing policy limits, coverage limitiations & expiration date.
Current Carrier:
Policy #:
Exp. Date:
Phone:
Coverage Amount:
$

Confidential Information
If the answer to any of the following questions is "yes", please fax or e-mail (in word format) an explanation in complete detail on a separate sheet of paper with your license & malpr actice information.
1. Have any of the following ever been denied, revoked, suspended, not renewed, limited, or is there any ongoing or pending action with respect to these? Have you ever been reprimanded, suspended, placed under probation, subjected to disciplinary action, or fined in relation to any of the following?
  • State License
  • Board Certification
  • Professional Organization membership
  • Medicare, Medicaid, or other government program participation
  • Managed Care or other private health plan participation
2. Do you have any ongoing physical or mental impairment or condition (including any ongoing substance abuse condition) which would make you unable, without reasonable accommodation, to perform the essential functions of a chiropractor?
3. Does any such condition make you unable to perform these essential functions without direct threat to the health and safety of others?
4. Considering the essential functions of a chiropractor, are you suffereing from any communicable health condition that could pose a significant health and safety risk to your patients?
5. Have you ever been charged with, or convicted of a felony or misdemeanor?
6. Has your malpractice insurance ever been denied, suspended, cancelled, limited (such as excluding a specific area of practice from your coverage) or not renewed?
7. Are you currently, or have you ever been, involved in any open, pending, or closed malpractice claims or suits (regardless of how these were resolved)?

Days & Hours Available to Substitute
 
Mon.
Tues.
Wed.
Thurs.
Fri.
Sat.
Sun.
From:
To:

Specifications & Preferences for Desired Position
Pay & Benefits-
Base salary:
$ *weekly minimum
Benefits:
Location-
Country:
City:
State/province:

Release & Authorization

I acknowledge and agree that Michael McGurn D.C. and Associates (MMA) has a valid interest in obtaining and verifying information concerning my professional competence and in determining whether to enter into or continue an agreement with me for the provision of chiropractic services. Accordingly:

  1. I represent and warrant to MMA and their clients that the information contained in this application is accurate, true and complete to the best of my knowledge and belief, and I agree to inform MMA within ten days if any material change in such information occurs, whether before or after my entering into agreement with MMA for the provision of chiropractic services. I understand and agree that any misrepresentation, misstatement or omission - whether intentional or not on this application, or supporting documents, or any future failure to provide information relating to any material change could be grounds for non-acceptance or termination from participation in any future working relationship with MMA. I authorize MMA to consult with clinic administrators, members of medical staffs, malpractice carriers and other persons or entities (each a "Third Party") to obtain and verify information concerning my professional competence, character, mental or emotional stability, physical condition and moral and ethical qualifications. Such information includes without limitations any information relating to any professional liability action; suspension or curtailment of chiropractic privileges; or any information relating to professional liability insurance experience and exclusions. This authorization includes the right to inspect or obtain any documents, recommendations, reports, statements or disclosures relating to such matters. I also expressly authorize any Third Party to release this information to MMA and it's authorized representatives upon request. By submitting this application, I understand and agree that I accept certain conditions. I hereby knowingly release and forever discharge MMA, any Third Party and each of their authorized representatives from any and all liability, claims, demands, damages, rights, lawsuits, actions or causes of action of every nature whatsoever, and costs and expenses related to the same whether known or unknown, arising out of any acts of omissions in obtaining, verifying or providing information used in evaluating my application and in making subsequent inquires or determinations or in connection with subsequent proceedings, hearings or reviews relating to credentialing, clinical privileges or participation in any contracts with MMA. A photocopy or facsimile of this Release and Authorization will serve as the original. I understand MMA will use this information in confidence and solely in conjunction with my application for and/or continuing participation in a contract with MMA. For purposes of this release, I acknowledge that the term "MMA" includes Michael McGurn DC and Associates to which this application is submitted as well as any of its affiliated entities with which I have applied to become a provider, and any officers, employees, agents, consultants or other parties affiliated with this company who may have any responsibility for obtaining or evaluating my credentials or acting upon my application. I agree to provide MMA with signed verification of employment for any position I accept from MMA.

  2. I agree not to refer any positions offered to me by MMA to any other individuals for employment or any other purpose. Violation of this,will result in a $3000.00 payment to MMA by myself if that referred individual is employed, retained or independently contracted in any capacity whether temporary or otherwise.

  3. I agree not to work or be paid directly by MMA's Clients or MMA's Clients referrals to me for any healthcare related employment of any kind including but not limited to temporary work,exams,spinal screening,practice sitting, etc..., for a two year period after MMA's referral, unless contracted or agreed to by or through MMA. I will notify MMA immediately if I am offered any type of healthcare related work by MMA's Clients or MMA's Clients referrals. Violation of this agreement will result in a commission due MMA by me of $100 daily for each day worked in violation of this agreement up to a maximum of $3000.

Submitting this application does not entitle the applicant to represent himself or herself as contracted entity with MMA. The information requested by this application is for the purpose of evaluating the applicant's participation with regards to entering into a contract with MMA. Neither applicant nor MMA shall be construed to be the agent, employer or representative of the other.

I agree