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SupplementSolveglobal2023-12-11T16:57:58-07:00

SUPPLEMENTAL INFORMATION

Applicant Supplemental Information

Please complete and submit this request for supplemental information.

Step 1 of 3

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Name*
First Last
Address
Street Address City State / Province / Region ZIP / Postal Code
Email*
Phone*

I am a*
Highest Degree*
Year Graduated*
Years of Experience*
In what states are you currently licensed?*
- Alabama
- Alaska
- American Samoa
- Arizona
- Arkansas
- California
- Colorado
- Connecticut
- Delaware
- District of Columbia
- Florida
- Georgia
- Guam
- Hawaii
- Idaho
- Illinois
- Indiana
- Iowa
- Kansas
- Kentucky
- Louisiana
- Maine
- Maryland
- Massachusetts
- Michigan
- Minnesota
- Mississippi
- Missouri
- Montana
- Nebraska
- Nevada
- New Hampshire
- New Jersey
- New Mexico
- New York
- North Carolina
- North Dakota
- Northern Mariana Islands
- Ohio
- Oklahoma
- Oregon
- Pennsylvania
- Puerto Rico
- Rhode Island
- South Carolina
- South Dakota
- Tennessee
- Texas
- Utah
- U.S. Virgin Islands
- Vermont
- Virginia
- Washington
- West Virginia
- Wisconsin
- Wyoming
- Armed Forces Americas
- Armed Forces Europe
- Armed Forces Pacific
Do you have any past, present or pending felony convictions?*
- Yes
- No
Do you have any past, present or pending CMS/Medicate or insurance fraud investigations or disciplinary actions?*
- Yes
- No
Do you have any past, present or pending malpractice investigations or legal actions?*
- Yes
- No
Do you have any past, present or pending professional licensing investigations or disciplinary actions?*
- Yes
- No

Credentials / Competency*
- Occupational / Corporate Health
- Orthooedics / Biomechanics
- Sports / Athletic Training
- Ergonomics / Human Factors
- Dynamical Systems Sciece
- MSK Primary Care
- EMT / Nursing
- Applied Functional Science
- Mackenzie Technique
- Spinal Mobilization / Manipulation
- Orthotics / Footwear
- Trigger Point Dry Needling
- Motivational Interviewing
- Work independently providing MSK health services & population management.
- Comfortable using laptop, tablet, & phone applications
- Multilingual
Check all that apply
I declare that this information is true and correct.*
- Yes

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