TelEmergency Home

Information Request Form

Biographical Information

Last Name
First Name
Address 1
Address 2
City
State
Zip
Phone
Email

Current NP Certification: (check all that apply)

Family Acute Care Pediatrics
Gerontological Adult  

 

Location interested in working: (check all that apply)

Aberdeen Richton
Belzoni Rolling Fork
Lexington Ruleville
Marks
Monticello
Morton
Newton
Port Gibson    

 

Would you consider relocating?
Yes No

 

DEA certificate?
Yes No Applied for

 

Additional certifications: (check all that are current)

ACLS (Advanced Cardiac Life Support)
PALS (Pediatric Advanced Life Support)
ATLS (Advanced Trauma Life Support)
BCLS (Basic Cardiac Life Support)
TNCC (Trauma Nursing Core Course)
CATN (Course in Advanced Trauma Nursing)
NALS (Neonatal Advanced Life Support)
ATCN (Advanced Trauma Care for Nurses)
CEN (Certified in Emergency Nursing)
Other: Please list

 

Are you currently working as a Nurse Practitioner?
Yes No

 

How did you hear about us?