Name* First Last Date* MM slash DD slash YYYY Why are you interested in working at NCAP and are you familiar with Northern Colorado/ Wyoming?*Describe the types of care models you have worked in during your career/training (e.g. medically directed, medically supervised, solo). What is your preferred care model and your preferred level of independence/supervision in practicing? (NCAP uses a medically-supervised care team model.)*NCAP provides anesthesia services in three geographic areas. Which do you prefer?* NORTH pod: Fort Collins, Loveland, Greeley SOUTH pod: Lafayette, Longmont, Louisville WYOMING pod: Laramie Are you interested in:* W-2 employed position 1099 contract position Not yet sure, would like to discuss Please tell us about the practice characteristics that are the most important for your next career move (e.g. types of cases you prefer, your ideal work environment/culture, preferred hours of work/call per week, etc.).*Please give us an idea of your annual compensation expectations for this position?*Are you certified in the following required areas? BLS ACLS PALS ATLS BLS Expires: ACLS Expires: PALS Expires: ATLS Expires: Are you Board certified? Yes No Has your license ever been suspended, revoked, or denied? Have clinical privileges ever been denied to you, limited, revoked, etc.? Have you even been subject to disciplinary action by a state medical board or any facility at which you were credentialed?*Date of Board Certification What is the earliest date (month/year) you would be available to start working at NCAP? Also, please describe any advance notice requirement you have with your current practice. Do you have restrictive covenants in your current contract that might preclude you from joining NCAP?*For referral purposes, do you know any current NCAP providers?*How did you discover NCAP?* Referred by a current employee Gaswork.com NCAP website Met NCAP at a recruiting event Other Current Employee Referral Which recruiting event did you hear about NCAP at? Other Please Attach Resume*Max. file size: 300 MB.Additional Documents (references, case logs, etc) Drop files here or Select files Max. file size: 300 MB, Max. files: 10.
