Associate Information Page

First, please tell us a little about yourself. This information is confidential, and PRN Eye Associates will not share it without your permission.

First Name:	*
Middle Initial:
Last Name:	*
Login:	*
New Password:	*
Email address:	*
Street Address:	*
City:	*
State:	*
Zip Code:	*
Home phone:	*
Work phone:
Cell phone or Pager:
Fax number:
States licensed in and license numbers:
State:
License Number:
State:
License Number:
State:
License Number:
State:
License Number:
Type of employment desired:	Full-time   Part-time   Temporary   Temporary-to-Permanent
Desired geographic location:
Type of practice environment your are interested in
When will you be available for work?
Additional information	In addition to the above information, PRN requires a signed Placement Agreement, copy of your current CV, copies of all your state optometry licenses, and a copy of the face sheet from your professional liability insurance company.Please see the associates F.A.Q page for downloadable Placement Agreements and instructions.

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