Physician Assistant (AM Shift)

Location: 3065 W. Bancroft St. Unit A, Toledo, OH 43606
Department: Urgent Care & Infusion Center
Reports To: Medical Director/Managing Partners

Personal Information

Full Name *

Address *

City, State, ZIP *

Phone Number *

Email *

Preferred Contact Method *

Phone

Email

Are you legally authorized to work in the U.S.? *

Are you at least 18 years of age? *

Position Details

Position Applying For: *

Employment Type *

Part-Time

Full-Time

Preferred Shift *

Day

Evening

Weekend

Holiday

Available Start Date *

Are you willing to rotate between Urgent Care and Infusion Center duties? *

Licensure & Certification

Ohio Physician Assistant License Number *

License Expiration Date *

NCCPA Certification Number

NCCPA Certification Status

Supervising Physician Agreement Status

Prescriptive Authority *

Yes

No

DEA Registration Number

DEA Registration Status *

Active

Pending

NPI Number

Required Certifications

BLS

ACLS

Preferred Certifications

PALS

DOT

POCUS

Are you currently participating in continuing education (CME)? *

If yes, specify:

Education

Institution *

Degree/Program *

Year Completed *

PA Program Accreditation

ARC-PA

Other

Professional References

Provide two professional references (supervisors, mentors, or collaborating physicians):

Name *

Title/Relationship *

Phone/Email *

Name *

Title/Relationship *

Phone/Email *

Professional Statement

Please describe your motivation for joining University Urgent Care & Pharmacy and how your clinical background aligns with our Urgent Care and Infusion Center model.

Applicant Certification

By submitting this application, I certify that the information provided is accurate and complete. I understand that any misrepresentation or omission may result in disqualification or termination if employed. I authorize verification of credentials and references provided.

Signature (Typed) *

Date *

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