Solvere

INDEPENDENT CONTRACTOR’S REQUEST FOR AGENT REPRESENTATION

901 Calle Amanecer -Suite 300 San Clemente -CA 92673 I Tel -1.800.451.7811 I Fax -888.777.2067 I www.SOLVEREinc.com

IDENTIFYING INFORMATION

First Name M.I Last Preffered Name

Professional Suffixes (MD, RN, LCSW) Specialty

Email Address

Current Address (Street, City, State, Zip

Mailing Address (if different from current address):

Phone (Home) Phone (Office) Phone (Cell)

Emergency Contact (Not living with you) Emergency Contact Phone

CERTIFICATIONS
Federal Narcotics Registration (DEA) number (Enclose copy)	Date Certified
Certified by American Board of (Name)	Date Certified
Have you obtained Cardiopulmonary Resuscitation Certification OR attended a refresher course in the past two years?	Yes	No
If yes, certified by (AHA or Red Cross)	Expiration Date
Location of Training Session	Date Attended

IF THE ANSWER TO ANY OF THE FOLLOWING QUESTIONS IS YES, PLEASE PROVIDE DETAILS BELOW IN THE COMMENT FIELD PROVIDED.

TERMS AND CONDITIONS

I am the person herein described and identified; that the answers to the accompanying questions and statements made in this application are true and correct; that I am the lawful holder of the degrees listed; and that such degrees were procured in the regular course of instruction and examination without fraud or misrepresentation.<br />

I hereby authorize all hospitals, institutions or organizations, my references, personal associates, and all government agencies to release to Solvere or its designated representative any information, files or records requested by Solvere in connection with the processing of this application. I further authorize Solvere to release to hospitals or medical groups any information which is material to my application.<br>

I have carefully read the questions in the accompanying Independent Contactor’s Request for Agent Representation and have answered them completely, without reservation of any kind, and I declare under penalty of perjury that my answers and all statements made by me herein are true and correct and understand this is a self employed independent contractor relationship

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Corporate Headquarters
Solvere
901 Calle Amanecer, Suite 300
San Clemente, CA 29673

Phone 800.451.7811
Phone 949.488.8615
Fax 888.777.2067

info@solvereinc.com

LICENSURE
I have licensure in the following states	Year Issued	Current	Inactive	Pending	Number	Type

MEDICAL MALPRACTICE LIABILITY INSURANCE BACKGROUND IF THE ANSWER TO ANY OF THE FOLLOWING QUESTIONS IS YES, PLEASE PROVIDE DETAILS BELOW IN THE COMMENT FIELD PROVIDED.
1.Have you ever been refused a professional license?	Yes	No
2. Have you ever failed a licensing examination?	Yes	No
3.Have you ever been convicted of a felony or misdemeanor other then minor traffic violations?	Yes	No
4. Have you ever been called before any licensing board or professional association in connection with practice act violation or unethical conduct?	Yes	No
5. Have you ever been cited by any licensing agency on grounds for revocation or suspension of a professional license?)	Yes	No
6. Are you now or have you ever been the defendant in any malpractice case?	Yes	No
7. Have you ever had a claim filed against you for Medical Malpractice?	Yes	No
8. Have you ever been refused membership to a hospital medical staff?	Yes	No
9. Has your request for any specific clinical privileges ever been denied or granted with stated limitations?	Yes	No