* denotes required fields

Contact Information
First Name* Middle Name Last Name*
City State Zip Code
Phone * Pager Mobile
Fax Office Email *
Background Information
Provider Type * Board Status
Specialty * Sub-Specialty
Add Sub-Specialty
Undergraduate Medical School
Residency Fellowship
Add License
Visa Status
Professional Status
Additional Information
Referral Source
Referral Description
Additional Information
Custom Additional Information
Have you previously worked for Pinacle Health System?

Please provide three references. All fields are required. If you do not have one of the pieces of information, please enter "n/a". Any empty fields will cause your application not to be saved.

Reference 1 of 3 - Full Name
Reference 1 of 3 - Occupation
Reference 1 of 3 - Years known
Reference 1 of 3 - Email
Reference 1 of 3 - Telephone
Reference 2 of 3 - Full Name
Reference 2 of 3 - Occupation
Reference 2 of 3 - Years known
Reference 2 of 3 - Email
Reference 2 of 3 - Telephone
Reference 3 of 3 - Full Name
Reference 3 of 3 - Occupation
Reference 3 of 3 - Years known
Reference 3 of 3 - Email
Reference 3 of 3 - Telephone

Read carefully before signing.

The information which I have provided on this application is true and correct. I authorize the Pinnacle Health System ("PHS") to contact any organization or person named on this application, and any other source which PHS deems necessary to verify the statements on this application. I authorize all such sources to disclose information about me to PHS. I understand that my employment may be terminated if the information that I have furnished is false or misleading.

I understand that my employment is dependent upon my passing a pre-placement physical examination and I consent to taking the pre-placement physical examination, including a drug screen, and such future physical examinations as may be required by PHS.

Pennsylvania law requires criminal background checks for persons applying for employment with health care providers. I understand that my employment is contingent upon a satisfactory criminal background check. A child abuse registry inquiry may also be required under Pennsylvania law. I understand that I will be responsible for submitting such background check forms to the appropriate agencies. Failure to do will disqualify me from consideration for employment with PHS.

My typed name below shall have the same force and effect as my written signature.
CV Document
CV Document (Resume)

Please provide your most current CV in Month/Year format and explain any gaps.

If you have already provided a CV and are applying for an additional opportunity, you do not need to attach your CV again.