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*Last Name
*First Name	Middle Initial
*Home Address
*City
*State
*Zip
*Home Phone
Cell Phone
Other Phone
*Email
*Degree and Date Awarded
I HAVE A FLORIDA LICENSE Yes No
I HAVE A FL MEDICARE PROVIDER NUMBER Yes No
I HAVE A FL MEDICAID PROVIDER NUMBER Yes No
I HAVE PROFESSIONAL MALPRACTICE INSURANCE Yes No
HAS YOUR LICENSE TO PRACTICE IN ANY JURISDICTION BEEN SURRENDERED, SUSPENDED, OR REVOKED? Yes No
HAVE YOU HAD ANY MALPRACTICE CLAIM SETTLED OR PENDING WITHIN THE PAST TWO YEARS? Yes No
HAVE YOU BEEN REFUSED MEMBERSHIP ON ANY HOSPITAL STAFF? Yes No
HAVE YOUR PRIVILEGES AT ANY HOSPITAL BEEN SUSPENDED OR REVOKED? Yes No
HAVE YOU BEEN, OR ARE YOU PRESENTLY THE SUBJECT OF AN INVESTIGATION BY ANY STATE OR FEDERAL REGULATORY AGENCY REGARDING YOUR PROFESSIONAL ACTIVITIES? Yes No
HAVE YOU HAD ANY DEPARTMENT OF PROFESSIONAL REGULATION DISCIPLINARY ACTIONS WITHIN THE PAST TWO YEARS? Yes No