Please provide the name, title, and email address of a professional reference below (You are required to provide 3 total):

Please provide the name, title, and email address of a professional reference below (You are required to provide 3 total):

Please provide the name, title, and email address of a professional reference below (You are required to provide 3 total):

I hereby authorize Physician Providers Management Corp to verify my personal history through any facility, employer, agency or individual listed in the application and release Physician Providers and the facility or person to whom the inquiry is made from any and all claims or liability as a result of such inquiries. I verify that the information provided in the application is accurate and true. Any future agreement may be terminated should any of the information provided be found to be inaccurate. By typing my full name below, I am electronically agreeing to these terms.

I hereby authorize all hospitals, medical institutions or organizations, personal references, employers (past and present), business and professional associates (past and present), all governmental agencies and instrumentalities (local, state, federal, or foreign), all university transcript offices, all medical schools, and the Federation of State Medical Boards to release to state licensing boards / Physician Providers Management Corp any information, files, or records required by that particular board and/or Physician Providers Management Corp for its evaluation of my professional, ethical, and physical qualifications for licensure. By typing my full name below, I am electronically agreeing to these terms.