D4 Key Personnel.docx
DOCX document 15 KB Posted
- Solicitation number
- 36C24223Q0017
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Text version
D.4 Key Personnel Roster – Candidate’s for prescreening determination New Jersey Healthcare System – East Orange VAMC
RFQ: 36C24223Q0017
Candidate Number 1:
1. Full Name:
2. Residence address:
3. Cell Phone:
4. Email address:
5. NPI number:
6. DEA number:
7. State License and Date:
8. Medica Liability Insurance exp Date:
9. Credentialed and Privileged: Yes or No
10. National Criminal History Check (NCHC) copy provided if one has been conducted in the past: Yes or NO, copy if obtained required Candidate Number 2:
1. Full Name:
2. Residence address:
3. Cell Phone:
4. Email address:
5. NPI number:
6. DEA number:
7. State License and Date:
8. Medica Liability Insurance exp Date:
9. Credentialed and Privileged: Yes or No
10. National Criminal History Check (NCHC) copy provided if one has been conducted in the past: Yes or NO, copy if obtained required Candidate Number 3:
1. Full Name:
2. Residence address:
3. Cell Phone:
4. Email address:
5. NPI number:
6. DEA number:
7. State License and Date:
8. Medica Liability Insurance exp Date:
9. Credentialed and Privileged: Yes or No
10. National Criminal History Check (NCHC) copy provided if one has been conducted in the past: Yes or NO, copy if obtained required Candidate Number 4
1. Full Name:
2. Residence address:
3. Cell Phone:
4. Email address:
5. NPI number:
6. DEA number:
7. State License and Date:
8. Medica Liability Insurance exp Date:
9. Credentialed and Privileged: Yes or No
10. National Criminal History Check (NCHC) copy provided if one has been conducted in the past: Yes or NO, copy if obtained required Add additional candidate requirements if applicable below!
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