Job Application
Please complete the form below to apply for a position with El Consultorio PLLC.
Full Name
First Name
Middle Name
Last Name
Birth Date
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1920
Year
Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address
example@example.com
Phone Number
Position Applied
Please Select
Full Time Employment (40 hours)
Part Time Employment (less than 40 hours)
Independent Contractor
Intern – Undergrad
Intern – Graduate
Administrative
Other (describe):
How did you hear about us
Please Select
LinkedIn
Event
Social Media
Company Website
Family / Friend
A current staff member of the company
Other
Available Start Date
/
Month
/
Day
Year
Date
Do you speak and can provide services in Spanish?
Yes
No
Other
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
*
Yes
No
If not, please provide more information:
Have you ever worked for El Consultorio PLLC
*
Yes
No
Have you ever been convicted of a felony?
*
Yes
No
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
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