Physician Volunteer Form This particular form is specifically for licensed physicians. Advanced care providers i.e. APRN’s, CNP’s, or other licensed care providers i.e. RN’s, etc. should complete the Non-Physician Clinical Volunteer Application. Participant Info First Name* Last Name* Address Line 1* Address Line 2 City* State* Zip Code* Phone* Your primary contact number Date of Birth* Email* Drivers License* Please upload a picture of your state issued Drivers License or comparable ID. Immunization Records* Please upload a copy of your current immunization records. Verification of TB Test* Please upload a verification of receiving a TB Test within the past 12 months. Verify you are not a robot!* 2 × 4 = ? Physicians Medical License Number* Practice Speciality* Please state your medical speciality. Current Employer/Practice* Privileges* At which hospitals/medical centers do you currently have privileges to practice? Licensed States In which states are you currently licensed to practice medicine?