Job Application Form

Job Application

Please complete the form below to apply for a position with El Consultorio PLLC.
Full Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
example@example.com
Phone Number
Position Applied
How did you hear about us
Available Start Date

MonthDayYear
Date
Do you speak and can provide services in Spanish?

YesNoOther
Include any information about your confidence in offering services in Spanish:. (This is not a disqualifying of employment/internship opportunity)
Credentialing Documents (for clinical positions)

Please complete the following information, if you do not have this information at this time, it is okay, more information will be provided in person or during the interview process.
DORA License Number Information (if applicable)
Please upload a copy of your DORA License Verification (if applicable)

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If your job requires a DORA registration, if you do not have one, please describe he status of your DORA registration (e.g. in process, under review, etc)

Please provide the following credentialing information:

	Yes	No	In Process	If Yes, Provide #
NPI #:
CAQH #:
Medicaid Individual #:
Other Credentialing Information:

Are you authorized to work in the United States*

YesNo
If not, please provide more information:
Have you ever worked for El Consultorio PLLC*

YesNo
Have you ever been convicted of a felony?*

YesNo
If yes, provide more information:
Upload Your Resume

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Cover Letter and other information that you would like to add to this application
Should be Empty:

Job Application