Moonlighter Interest Form

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Applicant information
(required fields are marked with *)
Name*
First Last
Address
Street Address Address Line 2 City State ZIP Code
Home Phone
Cell Phone*
Pager
Primary Email*
Secondary Email
Number of shifts desired per month:
Available for staffing as of:
MM slash DD slash YYYY
What services are you interested in? Select all that apply.
- General Surgery
- Cardiothoracic Surgery
- Urology & C-Section Assist
Would you be interested in being credentialed for cardiothoracic surgery as well?
- Yes
- No
Do you have an unrestricted Pennsylvania license?*
- Yes
- No
NOTE: An unrestricted PA license is required to begin the credentialing process. A training or limited license (e.g., for residency or fellowship) does NOT qualify as an unrestricted license for moonlighting. Please continue completing this form, apply with the state online, and let us know once you've received it.
Do you have a DEA license?*
- Yes
- No
Degree(s) completed?*
Are you currently an employee of Main Line Health System?*
- Yes
- No
Education
Medical School/Nursing School/Physician Assistant School
Please include institution and date completed.
Internship
Please include institution and date completed.
Residency & Year
Please include institution and date completed or anticipated completion date.
Residency Specialty
Please indicate the surgical specialty in which you are training or completed training.
Fellowship
Please include institution and date completed or anticipated completion date.
Please upload your CV here.*
Max. file size: 32 MB.
How did you hear about us?*

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Applicant information

Education